bluuebunny/crossref_metadata_2025 huggingface dataset:
Selective Unilateral Spinal Anaesthesia for Outpatient Knee Arthroscopy Using Real-Time Monitoring of Lower Limb Sympathetic Tone
Authors: Bergmann I. , Hesjedal B. , Crozier T. A. , Pöschl R. , Bauer M. , Hinz J. M. , Büttner B.
Published: January 2019

Selective unilateral spinal anaesthesia is a useful approach for ambulatory lower limb surgery because it allows more rapid home discharge compared to bilateral block. Infrequent use is due to the fact that obtaining selective unilateral block can be difficult, requiring attention to technique. We present a method with a high success rate that uses real-time monitoring of the sympathetic activity of the legs. In this prospective study, 56 patients scheduled for ambulatory knee arthroscopy had spinal anaesthesia in the lateral recumbent position, with hyperbaric bupivacaine 0.5% injected at 0.33 ml/min up to a maximum dose of 5 mg. Sympathetic tone of the legs was monitored by plantar electrical dermal resistance. The clinical effect was assessed by loss of sensation and muscle strength. The haemodynamic course and adverse events were monitored. The motor block was strictly unilateral in 55 patients (98%) and the sensory block was strictly unilateral in 53 patients (94%). The median decrease in systolic blood pressure was 6 mmHg. The time from subarachnoid puncture to arrival in the recovery room was 73 ± 23 minutes; the duration of stay in the recovery room was 70 ± 30 minutes. Three patients with a well-established block of adequate extent required conversion to general anaesthesia because of tourniquet pain. Urinary retention only occurred in the sole patient with bilateral block. This method of performing selective unilateral spinal anaesthesia using real-time monitoring of sympathetic tone of the legs has a high success rate and is associated with rapid eligibility for home discharge.
Electromagnetic Needle Tracking during Simulated Right Internal Jugular Cannulation
Authors: Faulke D. J. , Hall T. H. , Nixon C.
Published: January 2019

This study used three-dimensional information from Stealth navigation technology during simulated right internal jugular vein cannulation to define the initial needle trajectory taken when using three approaches: landmark (LM), short-axis (SAX) ultrasound and long-axis (LAX) ultrasound. Nineteen volunteers indicated the entry site and needle direction (track) they would use in performing right internal jugular vein cannulation by the three approaches. The likelihood of cannulation success, arterial puncture and needle direction were recorded. Volunteers were asked to assess the suitability of the simulation system for validity and educational benefit. The SAX track crossed the jugular vein more frequently than the LAX and LM tracks (SAX: 94%; LAX: 80%; LM: 47% [SAX versus LM, P <0.01]). The mean indicated needle direction in the coronal plane for LM, SAX and LAX were -4, 13 and 11 degrees, respectively. The track associated with the LAX technique would have entered the carotid artery by 16% of volunteers. At needle depths of over 40 mm, the track crossed the vertebral artery at the following rates (LM: 11%; SAX: 16%; LAX: 16%). The use of Stealth technology to provide three-dimensional feedback of the needle path taken during simulated right internal jugular cannulation was considered realistic (16/19) and of benefit for 18 of 19 (95%) respondents. The SAX track was associated with the highest likelihood of successful jugular cannulation and the lowest cross rate of the carotid artery. The simulation model using Stealth was considered to be valuable and realistic by participants despite some limitations.
Efficacy of an Enteral Feeding Protocol for Providing Nutritional Support after Paediatric Cardiac Surgery
Authors: Yoshimura S. , Miyazu M. , Yoshizawa S. , So M. , Kusama N. , Hirate H. , Sobue K.
Published: January 2019

Enteral nutrition (EN) is considered to be a more appropriate method than parenteral feeding for providing nutrition to critically ill children. However, children who undergo cardiac surgery are at high risk of postoperative gastrointestinal complications during EN. The purpose of this study was to demonstrate the safety and efficacy of our EN feeding protocol after paediatric cardiac surgery through comparison between a single-centre prospective case series and historical cases. Forty-seven children who were admitted to the ICU after cardiac surgery were enrolled (‘post group’). Data for these children were compared with a similar cohort of children who were admitted before the implementation of the feeding protocol (n=62; ‘pre group’). The incidence of complications including vomiting, necrotising enterocolitis and hypoglycaemia; the time until the initiation of EN; and the changes in calories provided were compared between the groups. The frequency of vomiting was significantly lower in the post group than in the pre group (36.2% versus 58.0%, P=0.038), and necrotising enterocolitis did not occur in either group. The time until the initiation of EN and the total calories provided did not differ significantly; however, in the post group the proportion of energy provided by parenteral nutrition was significantly smaller ( P <0.001), and provided by EN was significantly larger ( P=0.003), than in the pre group. The frequency of hypoglycaemia was similar in both groups. This study showed that our EN protocol resulted in adjustments to calories provided via EN versus parenteral nutrition after paediatric cardiac surgery, and reduced the frequency of vomiting.
Factors Associated with Vancomycin Nephrotoxicity in the Critically Ill
Authors: Hanrahan T. P. , Kotapati C. , Roberts M. J. , Rowland J. , Lipman J. , Roberts J. A. , Udy A.
Published: January 2019

Vancomycin is a glycopeptide antibiotic commonly used in the management of methicillin-resistant Staphylococcus aureus infection. The recent increase in prevalence of methicillin-resistant Staphylococcus aureus with reduced susceptibility to vancomycin has prompted experts to advocate for higher target trough serum concentrations. This study aimed to evaluate the potential consequences of more aggressive vancomycin therapy, by examining the association between higher serum concentrations and acute kidney injury (AKI) in a population of critically ill patients. We collected data for all patients who received vancomycin over a five-year period and evaluated the prevalence of new-onset AKI using the Risk, Injury, Failure, Loss and End-stage (RIFLE) kidney disease criteria. One-hundred and fifty-nine patients provided complete data, with 8.8% manifesting new onset AKI while receiving vancomycin. The median age was 57 (44 to 68) years, while the median trough serum concentration was 16 (10 to 19) mg/l. Multivariate logistic regression analysis identified mean trough concentration (OR=1.174, P=0.024), APACHE II score (OR=1.141, P=0.012) and simultaneous aminoglycoside prescription (OR=18.896, P=0.002) as significant predictors of AKI. These data suggest higher trough vancomycin serum concentrations are associated with greater odds of AKI in the critically ill.
High Altitude Hypoxia, A Mask and a Street. Donation of An Aviation BLB Oxygen Mask Apparatus from World War 2
Authors: Cooper M. G. , Street N. E.
Published: January 2019

The history of hypoxia prevention is closely inter-related with high altitude mountain and aviation physiology. One pioneering attempt to overcome low inspired oxygen partial pressures in aviation was the BLB mask—named after the three designers —Walter M Boothby, W Randolph Lovelace II and Arthur H Bulbulian. This mask and its variations originated just prior to World War 2 when aircraft were able to fly higher than 10,000 feet and pilot hypoxia affecting performance was an increasing problem. We give a brief description of the mask and its designers and discuss the donation of a model used by the British War Office in October 1940 and donated to the Harry Daly Museum at the Australian Society of Anaesthetists by the family of Dr Fred Street. Dr Street was a pioneering paediatric surgeon in Australia and served as a doctor in the Middle East and New Guinea in World War 2. He received the Military Cross.
The Venturi Bronchoscopic Attachment—Paediatric Considerations
Authors: Brown T. C. K.
Published: January 2019

Experiments on puppies were carried out during bronchoscopy to ascertain how the principle of intermittent inflation using a high-pressure gas source via a needle in the lumen of the bronchoscope could be safely applied to children under relaxant anaesthesia.

The effects on blood gases, intratracheal pressure and temperature with different source pressures were studied. The dangers and disadvantages of high source pressures are discussed.

PaCO2 and PaO2 were maintained with source pressures of 20 pounds per square inch (psi) at 30 breaths per minute, and at this level intratracheal pressures were also safe.

Temperature was shown to fall.

It has been safely applied clinically and two children were studied using 20 psi source pressure.
Tetanus: Principles of Management and Review of 37 Cases
Authors: Saady A. , Torda T. A.
Published: January 2019

Thirty-seven patients were treated for tetanus. Of these, 24 required neuromuscular blockade and intermittent positive pressure ventilation; the remaining 13 were managed chiefly with diazepam. Of the eight deaths in the series, three were the direct or indirect result of gastrointestinal complications. A management regime for tetanus is outlined and the complications that were encountered are discussed.
Total Spinal Anaesthesia
Authors: Evans T. I.
Published: January 2019

One hundred patients were given total spinal anaesthesia for major intra-abdominal surgery. Operating conditions were excellent, superior to that provided by relaxant general anaesthesia and free from hiccough and other reflex phenomena. However, the technique developed in this study provided anaesthesia which is too inflexible for widespread acceptance at present.
The Fat Embolism Syndrome, Results of a Therapeutic Regime
Authors: Baker A. B.
Published: January 2019

Results of a therapeutic regime for the fat embolism syndrome are presented. The basis of this regime is to prevent hypoxia by use of oxygen and if necessary intermittent positive pressure, ventilation. Prophylactic oxygen therapy in patients likely to develop the fat embolism syndrome is suggested.
The Influence of Examinations on Anaesthetic Training
Authors: Dreosti A. V. , Sando M. J. W.
Published: January 2019

The relationship of examinations to teaching and training is discussed with particular reference to the examinations of the Faculty of Anaesthetists of the Royal Australasian College of Surgeons.
Efficacy of High Volume Low Pressure Cuffs in Preventing Aspiration
Authors: McCleave D. J. , Fisher M.
Published: January 2019

The incidence of aspiration in patients with indwelling high volume, low pressure cuff endotracheal and tracheostomy tubes was assessed. A simple technique to routinely determine the correct inflation pressure of cuffs is recommended.
The Effect of Hyoscine and Atropine on the Lower Oesophageal Sphincter
Authors: Brock-Utne J. G. , Rubin J. , McAravey R. , Dow T. G. B. , Welman S. , Dimopoulos G. E. , Moshal M. G.
Published: January 2019

The effects of intravenous hyoscine 0·4 mg and atropine 0·6 mg on lower oesophageal sphincter tone were studied in normal human subjects. Hyoscine and atropine both decreased the lower oesophageal sphincter (L.O.S) pressure by approximately 11 cm H2 O (p <0·01). There was also an increased incidence of reflux as seen by an indwelling pH electrode in the lower oesophagus.

These findings are relevant to the preoperative preparation of patients presenting for emergency obstetrical anaesthesia; since gastro-oesophagus reflux and pulmonary aspiration of acid gastric content continues to be a significant cause of morbidity and mortality.
The Effect of Metoclopramide on the Lower Oesophageal Sphincter in Late Pregnancy
Authors: Brock-utne J. G. , Dow T. G. B. , Welman S. , Dimopoulos G. E. , Moshal M. G.
Published: January 2019

The effects of intravenous metoclopramide (Maxolon) on the lower oesophageal sphincter (LOS) were studied in three groups of patients, one group being normal control and the other two being pregnant females, one without heartburn and the other with.

Metoclopramide increases the LOS pressure 20.5, 15.2 and 10.2 cm H2 O respectively (p<0.005, p<0.005 and p<0.05).

These findings suggest that for patients undergoing elective or emergency obstetrical anaesthesia, intravenous metoclopramide may help reduce the incidence of regurgitation of gastric contents.
Increases in Cuff Volume and Pressure in Red Rubber Endotracheal Tubes during Anaesthesia
Authors: Thompson W. R. , Oh T. E.
Published: January 2019

Increases in endotracheal tube cuff volume and pressure during anaesthesia have been reported to be due to the diffusion of nitrous oxide into the cuff. This study compared cuff volume and pressure changes in anaesthetized intubated patients who were ventilated with those allowed to breath spontaneously. The cuffs of Magill red rubber endotracheal tubes were inflated with either air or a nitrous oxide-oxygen mixture.

Serial pressure and volume recordings confirmed that both parameters increased when the cuff was inflated with air. The increase in cuff pressure was however, greater during intermittent positive pressure ventilation than for spontaneous respiration. There were no significant changes when the cuff was inflated with the nitrous oxide-oxygen mixture.
Althesin for Neuroanaesthesia
Authors: Saady Albert
Published: January 2019

Althesin was used as an induction agent then diluted and administered as a controlled infusion for 60 patients undergoing 66 procedures. Incremental doses of fentanyl were given to provide additional analgesia. There was delayed awakening in 7 patients (12.1%), 3 of whom responded rapidly to narcotic reversal with naloxone. Intracerebral pathology and surgical trauma contributed to the slow recovery in the other 4 patients. Evidence is presented that Althesin infusions reduce the narcotic requirement. Althesin anaesthesia provides good neurosurgical conditions without delay in recovery.
Central Neural Blockade and Caesarian Section II: Patient Assessment of the Procedure
Authors: Brownridge Peter , Jefferson Jenny
Published: January 2019

A confidential questionnaire was sent to 62 mothers who had chosen central neural blockade for caesarian section. 82.5% replied to open and closed questions about their motives for and memories of the experience. Despite several sources of discomfort during surgery and in the postoperative period the overall response was overwhelmingly positive towards the procedure. The results of this pilot study indicate the importance of considering maternal aspirations prior to caesarian section, and allowing the informed mother to choose between central neural blockade and general anaesthesia whenever possible.
Practical Anaesthesia: The Anaesthetic Management of Major Spinal Surgery in Children
Authors: Church J. J. , Davidson G. M.
Published: January 2019

The anaesthetic management of patients requiring surgical correction of idiopathic scoliosis using the Harrington Rod Instrumentation Technique is discussed. Special emphasis is made of the need to minimise blood loss, to limit homologous blood transfusions and to provide adequate postoperative analgesia.
Transthoracic Right Atrial Cannulation for Total Parenteral Nutrition — Case Report
Authors: Hayden L. , Stewart G. Ramsey , Johnson D. C. , Fisher M. McD.
Published: January 2019

A man with severe peripheral vascular disease and requiring total parenteral nutrition because of short bowel syndrome was referred because a central venous catheter could not be inserted by conventional techniques. A right thoracotomy was performed and a Hickman catheter inserted via the right atrial appendage into the right atrium. This catheter was used for a total of seven months for total parenteral nutrition. For the last two months of this time, the patient was maintained at home on a Home Parenteral Nutrition Programme. After four months of total parenteral nutrition the patient developed recurrent fevers and the catheter was found to have migrated from the right atrium into the pulmonary artery.

The catheter was resited under x-ray control and used for a further three months until the recurrence of fever and dyspnoea heralded the onset of septic pulmonary emboli resulting in his death.
Neural and Neurochemical Mechanisms of Pain Inhibition
Authors: Liebeskind John C. , Sherman Jack E. , Cannon Timothy
Published: January 2019

Recent studies which suggest the existence of an endogenous neural substrate of pain inhibition are reviewed. Electrical stimulation of some areas of the medial brain stem in laboratory rats has produced a dramatic degree of analgesia. Such stimulation-produced analgesia is partially blocked by an opiate antagonist drug. This observation has proved seminal to those searching for endogenous opiate-like neurochemicals, the opioid peptides (enkephalins and endorphins). Particular attention is focused on studies of stimulation-produced analgesia, the underlying anatomy and physiology of endogenous analgesia systems elucidated by such work, and the relation of these findings to discoveries about opiate receptors and opioid peptides. Very recent work suggesting that certain forms of stress are natural triggers for activating endogenous analgesia mechanisms is described. Although certain stressors cause analgesia mediated by opioids, other stressors cause analgesia by neurochemically different means. Thus, multiple analgesia substrates, opioid and nonopioid, appear to exist.
A Rational Approach to Crossmatching Blood for Elective Surgery
Authors: Dodds Anthony J. , Pun Anthony , Isbister James P. , Ting Amy , Klarkowski Derryck , Concannon Alan J. , Biggs James C.
Published: January 2019

A group-and-screen system was introduced for selected surgical procedures to improve the cost-effectiveness of the hospital blood transfusion service. The mean crossmatch-transfusion ratio for eleven procedures was 11.1 but fell to 3.3 after the change. The overall crossmatch-transfusion ratio in the hospital improved from 2.7 to 2.2 (p <0.001) and blood wastage by expiry fell from 12% to 5% (p <0.02). The mean age of blood being transfused also improved slightly from 12.3 days to 10.4 days (p <0.001).

No problems have arisen from the group-and-screen system to date. It has led to improvement in the efficiency and cost-effectiveness of the hospital blood bank and resulted in fresher blood being transfused.
An Evaluation of Body Temperature Measurement
Authors: Ilsley A. H. , Rutten A. J. , Runciman W. B.
Published: January 2019

The accuracy of routine body temperature measurements, the suitability of various sites for such measurements, and the performance and practicality of various temperature measuring devices were studied. Oral and axillary temperature measurements made by the nursing staff were within 1°C of a reference value (within 0.5 °C in 67%). Both sites were suitable for routine ward temperature measurement. Mercury-in-glass thermometers are recommended for routine ward use. Electronic and disposable chemical thermometers cost more but the latter are suitable in uncooperative patients and children. Forehead skin temperature measurements using liquid crystal plastic discs were unreliable. Pulmonary artery and rectal temperature measurements were satisfactory in operating theatre and intensive care unit; however, electronic thermometers should be subjected to routine checks. The bladder temperature measuring device proved unsuitable for clinical use. When oesophagus, nasopharynx and tympanum sites are used careful placement is necessary to minimise trauma and obtain reliable measurements.
Hypotensive Effect of Mannitol Administered Rapidly
Authors: Domaingue Charles M. , Nye Daryl H.
Published: January 2019

Mannitol is an osmotic diuretic commonly used to reduce intracranial pressure. While various side-effects, including hyperosmolar states, precipitate reduction in intracranial pressure, rebound phenomenon and hypervolaemia have been described, hypotension due to rapid administration has not been widely recognised.
Monitoring Heart and Breath Sounds by Telemetry
Authors: Sainsbury D. A.
Published: January 2019

A system for FM radiotelemetry of heart and breath sounds is described. Patients’ heart and breath sounds are detected by oesophageal or precordial stethoscopes. The anaesthetist, carrying a portable radio receiver, is then free to move around theatre while listening to these sounds through headphones or an ear-piece. The FM telemetry system has also been used to assist patient monitoring in noisy environments such as ambulances.
The Spread of Caudal Analgesia in Children: A Mathematical Model
Authors: Busoni P. , Andreuccetti T.
Published: January 2019

A mathematical model correlating the spread of analgesia to the dose of local anaesthetic and to age or body weight was found analysing the data of 763 caudal blocks in children from age one day to twelve years. Two graphs have been plotted: (1) spread of analgesia, dose, age and (2) spread of analgesia, dose, weight.

Both age and weight can be used as predictors to determine the desired level of analgesia, but weight is more useful in very young patients while age is a better guide in older children.
A Re-Evaluation of the Anxiolytic Properties of Intramuscular Midazolam
Authors: Artru A. A. , Dhamee M. S. , Seifen A. B. , Wright B.
Published: January 2019

The observed effect of midazolam on anxiety is equivocal in part because previous studies have not ruled out pre-treatment differences in anxiety scores between patients who received midazolam and those who did not (controls). This study re-examines the anxiolytic effect of premedication with intramuscular midazolam using a sample size calculated to be of sufficient size to rule out population differences as a variable affecting treatment results. In the midazolam group (n = 49) anxiety scores were determined prior to administration of midazolam 0.07 mg/kg intramuscularly, and again 60 minutes later. In the control group (n = 47) anxiety scores were determined prior to intramuscular injection of a similar volume of matching placebo (midazolam vehicle), and again 60 minutes later. No differences in anxiety scores between groups either before treatments or 60 minutes after treatments were observed. Within both groups, anxiety scores at 60 minutes were no different from pre-treatment scores. In this study midazolam did not produce a statistically significant decrease in pre-operative anxiety scores at 60 minutes following intramuscular administration.
Adaptation of the Quadrupole Mass Spectrometer to Multipatient Anaesthesia Gas Monitoring
Authors: Salamonsen R. F. , Tulloh A. M. , Boyd T.
Published: January 2019

A series of modifications designed to increase the suitability of the quadrupole mass spectrometer for multipatient gas monitoring in the operating suite are presented and evaluated. The adaptations include a pressure-stabilised long capillary inlet system and computer control of the quadrupole filter together with tuning, calibration and subsequent multitheatre analysis and display of clinical information. A pilot study of three months clinical monitoring provided documentation of contributions towards the safety and effectiveness of anaesthesia. These included indication of equipment malfunction, and fluctuations in gas exchange associated with inappropriate ventilation, haemodynamic instability and variations in body temperature. Limited accuracy for carbon dioxide and a low signal-to-noise ratio together with rapid ageing of electron multipliers were identified as problems still only partially solved.
PEEP and CPAP
Authors: Duncan A. W. , Oh T. E. , Hillman D. R.
Published: January 2019

Positive end-expiratory pressure (PEEP) maintains airway pressure above atmospheric at the end of expiration, and may be used with mechanical ventilation or spontaneous breathing. CPAP, or continuous positive airway pressure, refers to spontaneous ventilation with a positive airway pressure being maintained throughout the whole respiratory cycle. PEEP/CPAP primarily improves oxygenation by increasing functional residual capacity, and may increase lung compliance and decrease the work of breathing. PEEP/CPAP may be applied using endotracheal tubes, nasal masks or prongs, or face masks or chambers to treat a wide range of adult and paediatric respiratory disorders. Complications associated with their use relate to the pressures applied and include pulmonary barotrauma, decreased cardiac output and raised intracranial pressure.
High-Frequency Ventilation
Authors: Crawford M. R.
Published: January 2019

Over the last six years high-frequency ventilation has been extensively evaluated both in the clinical and laboratory settings. It is now no longer the great mystery it once was, and it is now no longer believed (as many had hoped), that it will solve all the problems associated with mechanical pulmonary ventilation. Although the technique is safe and appears to cause no harm even in the long term, it has not yet been shown to offer any major advantages over conventional mechanical ventilation.
The ‘New’ Relaxants. A Review of the Clinical Pharmacology of Atracurium and Vecuronium
Authors: Torda T. A.
Published: January 2019

Atracurium and vecuronium are reviewed with reference to the following aspects: Development and chemistry

Pharmacology

Potency and dosage

Onset and duration of action

Non-neuromuscular effects

Cardiovascular

Central nervous system

Histamine release and allergic responses

Fate in the body

Pharmacokinetics

Factors which affect response to atracurium and vecuronium

Anaesthetic agents

Suxamethonium

Age

Clinical aspects

Intubation

Cardiac disease and cardiac surgery

Renal disease

Liver disease

Obstetric anaesthesia

Anaesthesia for ophthalmic and neurosurgery

Intercurrent disease states

Outpatient surgery

Reversal of neuromuscular block

Conclusion
Oxygen Saturation during Transfer from Operating Room to Recovery after Anaesthesia
Authors: Blair I. , Holland R. , Lau W. , McCarthy N. , Chiah T. S. , Ledwidge D.
Published: January 2019

Transcutaneous oxygen saturation of haemoglobin was measured in 101 patients en route from the operating room to the recovery room. Twenty-nine became significantly hypoxaemic during the journey.

The incidence of hypoxaemia was not found to relate to age, weight, duration or type of surgery, type of anaesthesia or pre-existing disease. Duration of the interval between cessation of oxygen in the operating room and arrival in recovery room was the only significant finding in patients who became hypoxaemic.
Failure of Intravenous Infusions from Extravasation and Phlebitis
Authors: Hecker J. F.
Published: January 2019

A survey was done to compare the rates at which phlebitis and extravasation cause failure of intravenous infusions lasting more than 24 hours. Slightly more infusions failed due to phlebitis than to extravasation but extravasation did not occur earlier or later than phlebitis or differ significantly from it in frequency when different types of infusions were compared. Univariate life table analysis indicated that the co-infusion of blood, potassium or cephalosporin antibiotics slightly increased and that higher flow rates markedly increased failure, that infusions including continuous heparin and steroids had markedly decreased failure, and that failure was not significantly affected by other antibiotics or by differences in sex, age, location of infusion site or time of year. Multivariate analysis showed that the above differences were statistically significant only for infusion rate, heparin and steroids.
Digoxin-like Immunoreactive Substances in the Plasma of Intensive Care Unit Patients: Relationship to Organ Dysfunction
Authors: Howarth D. M. , Sampson D. C. , Hawker F. H. , Young A.
Published: January 2019

Digoxin-like immunoreactive substances are an endogenous group of compounds that cross-react in conventional immunoassays for digoxin. Plasma digoxin-like immunoreactive substance concentrations were estimated using the Abbott TDxll fluorescence polarisation immunoassay kit for digoxin. Digoxin-like immunoreactive substances were measured in one hundred consecutive Intensive Care Unit (ICU) patients who were not treated with digoxin. One hundred healthy blood donors were used as controls. Thirty of the ICU patients had plasma digoxin-like immunoreactive substance concentrations greater than or equal to the greatest value found in the control group (0.22 nmol/l). In the ICU group the median value was 0.17 nmol/l and the range zero to 1.69 nmol/l. In the control group the median was less than the limit of detection of the assay, and the range zero to 0.22 nmol/l. Sixteen ICU patients had coexisting renal and hepatic dysfunction and this group had a median digoxin-like immunoreactive substance concentration of 0.21 nmol/l (range zero to 1.69 nmol/l), while 38 patients with hepatic dysfunction and normal renal function had a median concentration of 0.17 nmol/l (range zero to 0.77 nmol/l). In contrast four patients with renal dysfunction only had a median concentration of 0.05 nmol/l (range zero to 0.34 nmol/l). The remaining forty-two patients had neither hepatic nor renal dysfunction and this group had a median concentration of 0.15 nmol/l (range zero to 0.36 nmol/l). This study has identified the critically ill as a group of patients who exhibit measurable plasma digoxin-like immunoreactive substances using the most commonly used kit for analysis of digoxin.
The Place of Caudal Anaesthesia in Obstetrics
Authors: Paull J. D.
Published: January 2019

Present day trainee anaesthetists could be forgiven if they finished their anaesthetic training believing that caudal anaesthesia in obstetrics is not only unnecessary, but dangerous and a relic of the past. Many anaesthetic texts teach applications and techniques which are little or no advance on the teachings of Hingson and Edwards in 1942 and reflect nothing of the true value and application of this valuable block. This paper presents a critical review of these texts and of the results of the use of the block in a busy obstetric unit.
Arterial Lignocaine Concentrations following Cervical Plexus Blockade for Carotid Endarterectomy
Authors: Dawson A. R. , Dysart R. H. , Amerena J. V. , Braniff V. , Davies M. J. , Cronin K. D. , Mashford M. L.
Published: January 2019

Arterial lignocaine concentrations were measured in twenty-six patients who had carotid endarterectomy performed under deep and superficial cervical plexus blockade. A dose of 6 mg/kg of 1.5% lignocaine with 1:200,000 adrenaline was used, as well as additional supplementation by the surgeons when required. Concentrations obtained produced a mean peak of 5 fig/ml and were similar to those previously reported from multiple bilateral intercostal blockade, which is the regional technique widely considered to produce the highest systemic levels of local anaesthetic. Apart from one peak concentration of 16.9 μg/ml, levels were well below the convulsion threshold. We find the technique acceptable and safe for carotid surgery and lignocaine toxicity is not identified as a problem.
The Lumbosacral Epidural Block: A Modified Taylor Approach for Abdominal Urologic Surgery in Children
Authors: Busoni P. , Messeri A. , Sarti A.
Published: January 2019

We describe the lumbosacral epidural approach in 97 children undergoing abdominal urologic surgical procedures. Due to the rudimentary spinous process of the first sacral vertebra and the less prominent sacral angle, an appropriate upward inclination of the Tuohy needle in the midline is always possible in infants and small children. A catheter was easily inserted in every case and the technique was shown to be useful and safe for providing adequate intraoperative and postoperative pain control.
Postoperative Analgesia for Oesophageal Surgery: A Comparison of Three Analgesic Regimens
Authors: Tsui S. L. , Chan C. S. , Chan A. S. H. , Wong S. J. , Lam C. S. , Jones R. D. M.
Published: January 2019

Sixty-four patients undergoing oesophageal surgery were randomly allocated to receive either a continuous lumbar epidural infusion of morphine or fentanyl, or, intramuscular morphine for postoperative analgesia. There was no statistical difference in analgesic requirements between the patients who underwent a thoracotomy for their procedure (n = 50) and those who did not (n = 14), as assessed by the total dose of opioid administered, visual analogue scale (VAS) and pain score (PS) comparison. However, by these criteria, epidural morphine infusion provided the most satisfactory analgesia (P < 0.05). Despite the variable quality of analgesia achieved with the three regimens, the postoperative lung function tests were similar for all groups, and we conclude that routine lung function tests are not an appropriate method of comparing analgesic efficacy. Prophylactic administration of loratadine to 15% of our patients was not shown to be effective in diminishing the incidence of pruritus.
A Survey of Epidural Analgesia Practice in Western Australian Obstetric Units
Authors: Paech M. J. , Godkin R.
Published: January 2019

A survey of epidural practices in all obstetric units in this state was conducted to obtain information regarding epidural analgesia services, epidural conduct and management, management of complications and staff education.

The survey revealed a diversity of practice and in some instances standards of care. While reflecting the regionalisation of services in this geographically vast state, the problems identified appear universal and are likely to be relevant on a broader and national scale. Practices are discussed and recommendations made with respect to improvement of management and continuing education.
Granulocyte Transfusions — A Review for the Intensive Care Physician
Authors: Tobias J. D. , Schleien C.
Published: January 2019

In order to achieve the maximum therapeutic benefit in the treatment of malignancies, doses of chemotherapeutic agents are pushed to the point of severe marrow toxicity. This aggressive therapy can lead to iatrogenic complications including haemorrhage and sepsis due to the depletion of platelets and granulocytes. Prior to the advent of platelet transfusions, haemorrhage was the leading cause of death in these patients.1 Advances in blood banking and the availability of platelet transfusions have markedly decreased the incidence of fatal haemorrhage. As a result, infection has become the leading cause of death in patients with marrow failure.2 Although the risk of infection in patients with neutropenia has been well documented,3 the role of granulocyte transfusions in the treatment and prevention of these infections remains controversial. This paper will attempt to review the currently available literature regarding granulocyte procurement techniques and the efficacy of granulocyte transfusions.
Single versus Double Occlusive Dressing Technique to Minimize Infusion Thrombophlebitis: Vialon® and Teflon® Cannulae Reassessed
Authors: Myles P. S. , Buckland M. R. , Burnett W. J.
Published: January 2019

Infusion thrombophlebitis is the commonest complication of intravenous cannulation. This study was undertaken to prospectively evaluate a double-occlusive dressing technique and a new cannula, bismuth oxide-Teflon® (Critikon Inc., Aust.), comparing it to Vialon® (Deseret Medical Inc., Utah, USA). The study group of two hundred patients had a 16 gauge intravenous cannula inserted in theatre using a standard technique. The incidence of thrombophlebitis was determined on a daily basis. Cannula tips were sent for culture on removal.

Vialon® was found to be superior to Teflon® after day 1. Although a double-occlusive dressing technique increased the duration of cannulation (50.9 vs. 41.9 hours, P < 0.05), there was no difference in the incidence of thrombophlebitis. Neither cannula material nor dressing technique had an influence on the results of cannula tip culture (6% incidence). There was no evidence of bacteraemia in any case.
Caudal Blockade for Postoperative Analgesia: A Useful Adjunct to Intramuscular Opiates following Emergency Lower Leg Orthopaedic Surgery
Authors: McCrirrick A. , Ramage D. T. O.
Published: January 2019

The efficacy of a single caudal epidural injection of bupivacaine 20 ml 0.5% following emergency orthopaedic surgery to the lower leg and ankle was investigated. Forty adult patients were studied, randomised to either the caudal or control group. The mean 24 hour postoperative papaveretum consumption was significantly reduced in the caudal group. Analogue pain scores as assessed in a double-blind manner were also significantly reduced in this group. The duration of analgesia after caudal blockade was approximately eight hours as estimated by the average time to the first dose of papaveretum. Our study demonstrates that caudal blockade represents an effective adjunct to intramuscular opiates following this type of surgery.
Inter-Ethnic Differences in Postoperative Pethidine Requirements
Authors: Houghton I. T. , Aun C. S. T. , Gin T. , Lau J. T. F.
Published: January 2019

A preliminary study of 24 hours’ postoperative analgesia using a patient-controlled analgesia technique was undertaken in eight European and fourteen Asian adult patients. All patients had upper abdominal surgery and received weight-related doses of pethidine postoperatively via a Cardiff Palliator. Both groups had a similar degree of analgesia as assessed by visual analogue score but the Asian patients were more sedated in the postoperative period. The Asian patients made 24% fewer demands for analgesia and had a smaller mean (SD) pethidine consumption, 7.62 (2.04) mg.kg−1, compared with the European patients, 9.97 (2.14) mg.kg−1, (P < 0.05) during the first 24 hours. Further research is necessary to determine whether the smaller requirement for analgesia in Asian patients is a result of pharmacokinetic or pharmacodynamic differences.
Alveolar Oxygenation and Mouth-to-Mask Ventilation: Effects of Oxygen Insufflation
Authors: Stahl J. M. , Cutfield G. R. , Harrison G. A.
Published: January 2019

The effect on alveolar oxygen fraction (FAO2) of insufflating oxygen under a mask (or through an inflow nipple provided in the mask) during simulated mouth-to-mask ventilation was investigated using a lung model.

A variety of commercially produced masks were evaluated. Two patterns of artificial ventilation were applied: 1. 500 ml tidal volume at 20 breaths per minute, and 2. 900 ml tidal volume at 12 breaths per minute. The ventilating gas mixture was oxygen 16% in nitrous oxide, and oxygen was insufflated at flow rates of 2, 4, 6, 8, 10, 12 or 14 litres per minute.

The rate of rise of FAO2 and the equilibrium FAO2 attained were greatest at high oxygen inflow rates. The relationship between oxygen flow and FAO2 was not linear however, and an oxygen flow rate of 10 l/min was adequate to generate FAO2‘s around 50% with either ventilatory pattern. The equilibrium FAO2 achieved was greater with smaller tidal volumes and with larger mask deadspace.

We also found that several breaths were required for equilibration of FAO2 during each trial, supporting recommendations that several breaths should be given on commencement of artificial ventilation during cardiopulmonary resuscitation.
Laboratory Evaluation of the Go Medical PCI: A Disposable Patient-Controlled Analgesia Device
Authors: Mackey N. A. , Ilsley A. H. , Owen H. , Plummer J. L.
Published: January 2019

A low-cost, disposable patient-controlled analgesia device was tested using a computer-controlled, automated testing station designed to simulate clinical use. Five devices were tested and delivered a mean bolus dose size of 95% of nominal, although one device achieved only 85% of nominal. Delivery was lowest immediately following an eight-hour interval during which no demands were made. Further development and evaluation of this interesting device is warranted.
The Laryngeal Mask Airway: A Method to Improve Visualisation of the Trachea and Larynx during Fibreoptic Assisted Percutaneous Tracheostomy
Authors: Dexter T. J.
Published: January 2019

A modification of the Ciaglia multiple-dilator method for percutaneous tracheostomy using both a fibreoptic bronchoscope and laryngeal mask airway to visualise the upper airway, so as to aid in safer placement, is described.
Intensive Care Unit Resource Utilisation
Authors: Buist M.
Published: January 2019

The cost-effectiveness of the Intensive Care Unit after three decades of development has yet to be demonstrated. Accurate ICU resource allocation is limited by our inability to measure cost-effectiveness.

Measurement tools have been developed and refined that will give a prediction of in-hospital mortality of groups of critically ill patients. However, these measures will not predict with certainty individual patient outcomes, and take no account of quality of life. Methodology to examine long-term outcome and quality of life after intensive care is still in its infancy.

Measurement of ICU cost is limited by a lack of cost-accounting models that not only reflect true cost but that are clinically applicable.
Complex Regional Pain Syndromes: Including “Reflex Sympathetic Dystrophy” and “Causalgia”
Authors: Walker S. M. , Cousins M. J.
Published: January 2019

“Reflex sympathetic dystrophy” and “causalgia” are now classified by the International Association for the Study of Pain as Complex Regional Pain Syndromes I and II. Sympathetically maintained pain is a frequent but variable component of these syndromes, as the sympathetic and somatosensory pathways are no longer functionally distinct. Pain is the cardinal feature of CRPS, but the constellation of symptoms and signs may also include sensory changes, autonomic dysfunction, trophic changes, motor impairment and psychological changes. Diagnosis is based on the clinical picture, with additional information regarding the presence of sympathetically maintained pain or autonomic dysfunction being provided by carefully performed and interpreted supplemental tests. Clinical experience supports early intervention with sympatholytic procedures (pharmacological or nerve block techniques), but further scientific data is required to confirm the appropriate timing and relative efficacy of different procedures. Patients with recurrent or refractory symptoms are best managed in a multi-disciplinary pain clinic as more invasive and intensive treatment will be required to minimize ongoing pain and disability.
Survey: National Audit of Anaesthesia for Major Abdominal Surgery
Authors: Rigg J. R. , Collins K. , Jamrozik K.
Published: January 2019

A postal survey was conducted of all hospitals in Australia known to have a department of anaesthesia and an intensive care or high dependency unit.

Each hospital was asked to report the anaesthetic and postoperative analgesic techniques used for the last ten cases of four common major surgical procedures—aorto-femoral bypass, repair of an abdominal aortic aneurysm, hemicolectomy and anterior resection of the rectum.

Half of 76 hospitals sent a survey form completed and returned it. Responding hospitals were larger, on average, than non-responding ones, but otherwise typical of them in terms of university affiliation and metropolitan versus rural location. For each of the four procedures studied, the proportion of cases in which epidural block was used intra- or postoperatively varied from 0% to 100%. Depending on the procedure, between 65% and 85% of hospitals used epidural block sometimes, with between 10% and 90% of patients in these hospitals being managed with this technique.

There is wide variation in the use of epidural block, intra- and postoperatively, in Australia, variation that is unlikely to be explained by systematic differences between institutions in the patients seen or their suitability for one or other technique. This pattern of practice mirrors the lack of agreement about the proper place for epidural techniques evident in the recent literature. There is a widespread belief among clinicians that this is a question of great importance. Accordingly, we believe that anaesthetists and surgeons share an ethical responsibility to enter suitable patients in an appropriately designed randomized controlled trial in order to resolve this question.
Tracheostomy in a Neuro-Intensive Care Setting: Indications and Timing
Authors: Koh W. Y. , Lew T. W. K. , Chin N. M. , Wong M. F. M.
Published: January 2019

A retrospective review was made of 49 survivors who were mechanically ventilated for more than 48 hours in the neurosurgical ICU.

Thirty-two patients (Gp I) were successfully extubated, 9 patients (Gp II) underwent tracheostomy after one or more failed extubations, and 8 patients (Gp III) underwent elective tracheostomy. Glasgow Coma Scale (GCS) scores at extubation were 11.3±2.8 (mean (SD) for Gp I vs 7.8±2.7 for Gp II (P= n.s.) and at elective tracheostomy (Gp III) was 5.4±2.3. Incidence of ventilator-associated pneumonia were 35% in Gp I vs 100% of patients in Gp II and III (P<0.05). Reasons for reintubation in 7 of 9 patients (Gp II) were upper airway obstruction and tenacious tracheal secretions while 14 of 17 patients were weaned off the ventilator within 48 hours of tracheostomy. The length of stay in ICU was 16.8±7.1 days in Gp II vs 11.7±2.9 days in Gp III (P<0.05).

In our study, elective tracheostomy for selected patients with poor GCS scores and nosocomial pneumonia has resulted in shortened ICU length of stay and rapid weaning from ventilatory support.
A Study to Determine the Optimum Dose of Metaraminol Required to Increase Blood Pressure by 25% during Subarachnoid Anaesthesia
Authors: Critchley L. A. H. , Karmakar M. K. , Cheng J. H. H. , Critchley J. A. J. H.
Published: January 2019

We studied dosage optimization for metaraminol when managing hypotension during subarachnoid anaesthesia. Twenty patients aged 53 to 84 years, were recruited. Non-invasive blood pressure (BP) and heart rate were recorded one-minutely. A series of four IV metaraminol boluses (0.25 to 1.0 mg per 50 kg adult) were administered. From individual patient time plots of BP, predicted dosages for a 25% elevation in BP were estimated. Dose-related elevations in systolic BP [mean (SD)] occurred following dosages of 0.5 mg [25 (11)%] and 1.0 mg [50 (23)%]. Similar elevations occurred in mean and diastolic BP. Overall estimated dosage (median) to produce a 25% elevation in systolic BP was 0.5 mg (per 50 kg adult). However, individual patient responses varied (10–90th centiles=0.23 to 0.80 mg). Thus, we now recommend a starting dose of 0.25 mg, increasing to 0.5 mg if necessary, to treat hypotension (25% decrease in systolic BP) during subarachnoid anaesthesia.
Undernutrition in Children—Effect on Vecuronium Induced Neuromuscular Blockade
Authors: Jain A. K. , Hussain S. , Ahuja S.
Published: January 2019

Sixty children aged one to 12 years requiring anaesthesia including a muscle relaxant were assessed for their nutritional status based on simple anthropometric and biochemical parameters. They were allocated to one of four groups: normal nutrition, mild, moderate or severe malnutrition.

The neuromuscular effects of vecuronium bromide 0.1 mg/kg were studied by recording evoked responses to train of four (TOF) nerve stimulation using an accelerograph. In the above nutritional groups, time to onset of 25% depression of T1 was 0.8, 1.4, 1.3 and 2.1 minutes respectively. Maximal depression of TOF response was seen at 2.2, 3.2, 3.7 and 8.4 minutes. The duration of action of the initial dose was 26.5, 24.0, 17.7 and 13.3 minutes and the mean duration of action of top-up doses was 16.2, 14.9, 11.2 and 8.9 minutes respectively. Reversal time with neostigmine 0.05 mg/kg was not significantly different in the four groups. These results demonstrate a statistically significant delay in onset and shortening of the duration of action of vecuronium in the undernourished groups compared with the normal nutrition group when vecuronium is administered to children on a milligram per kilogram basis.