bluuebunny/crossref_metadata_2025 huggingface dataset:
Adverse Effects of Plasma Volume Expanders
Authors: Isbister James P. , Fisher Malcolm Mcd.
Published: January 2019

Plasma protein solutions and synthetic plasma substitutes have an established role in therapy in many areas of clinical medicine. Although there have been many advances in the field of plasma volume expanders, an effective, stable, readily available and economical solution, free from side effects remains elusive. In particular, all plasma volume expanders may be associated with a small, but significant incidence of side effects. Allergic and anaphylactoid reactions are the most feared, but questions about prolonged storage and effects on haemostasis and renal function should be considered.

Plasma protein fraction may be associated with hypotension, probably due to kinin activation. In the fully conscious patient, features of vasodilatation including flushing, fullness in the head, nasal stuffiness, may also be noted. There have also been reports of true anaphylactic type reactions occurring in atopic subjects after the infusion of small amounts of plasma protein solution. Modified fluid gelatins are well known to release histamine when infused rapidly. The reactions are usually confined to the skin and present clinically as pruritis, urticaria or flushing. There are also reports of anaphylactic reactions not related to dosage which are probably immune in origin. The dextrans are well recognised to cause such anaphylactoid reactions. Accepting that anaphylactoid and anaphylactic reactions may occur in association with plasma volume expanders, anticipation, diagnosis and rapid institution of therapy determine the outcome of these reactions.
Microfiltration of Stored Blood
Authors: Loong E. D.
Published: January 2019

Microaggregates begin to develop within a few hours of storage of blood in plastic or glass containers, but their numbers increase mainly towards the end of the first week. They include degenerated platelets, leucocytes, fibrin strands, denatured proteins and fragmented red cells, and range in size from 10 to 40 μm or more in diameter. The rate of formation is related to the platelet and leucocyte concentrations prior to storage and the anticoagulant used.

While clinical and experimental evidence of deleterious pulmonary effects of these unwanted particles has been limited and contradictory, recent studies have demonstrated that significant increases in pulmonary arteriovenous shunting and alveolar-arterial oxygen differences occur in patients transfused more than 20% of their blood volume through the standard 170 μm filters. These changes are not seen when the blood is passed through a 20 μm Dacron wool filter.

Other methods of reducing the microaggregate content of transfused blood include the use of fresh blood (less than 2 days), glycerol-frozen fresh blood correctly thawed, or saline-washed packed red cells.

Since none of these is feasible for routine use at present, removal by microfiltration prior to transfusion is employed. Of the filters currently available, the 40 μm screen filters appear to offer important practical advantages over the alternative depth filters. Routine filtration of all stored blood transfused is advocated.
Should Autologous Blood Transfusion be Rediscovered?
Authors: Isbister James P. , Davis Richard
Published: January 2019

With a greater appreciation and understanding of reactions to homologous blood transfusion there has been a renewed interest in autologous blood transfusion. The techniques and indications for preoperative banked autologous blood, perioperative haemodilution and recycled salvaged autologous blood transfusion are described. When circumstances permit, autologous blood transfusion is a safe, economical and efficient alternative to homologous blood.
Carbamazepine Poisoning, a Surprisingly Severe Case
Authors: Drenck Niels Eric , Risbo Allan
Published: January 2019

A case of carbamazepine (Tegretol®) poisoning is presented. The symptoms and signs were surprisingly severe after ingestion of only 10g. Treatment and unusual features of the case are discussed.
Spinal Anaesthesia for Paediatric Radiotherapy
Authors: Spencer H. T. , Barnes P. J.
Published: January 2019

Painful radiotherapeutic procedures on lower limbs are susceptible to spinal anaesthesia. This method is shown to be suitable in children when neuroleptanalgesia provides amnesia, an adequate period of patient immobility, and stable cardiovascular and respiratory conditions. The technique is useful in overcoming the problems of anaesthesia in the radiotherapy environment.
Pharmacology of Pain and Analgesia
Authors: Wilson Peter R. , Yaksh Tony L.
Published: January 2019

Physiological events involved in nociception and pain perception are examined. Substance P could be a primary afferent transmitter of certain nociceptive information. Transmission of this information can be modulated within the spinal cord by intrinsic and descending mechanisms. The intrinsic mechanism involves inhibitory opiate effects within substantia gelatinosa. Centres for descending systems are located in medulla and periaqueductal gray matter. They are activated by exogenous narcotic agonists, and by regional connections. Descending inhibitory pathways are serotonergic and noradrenergic. GABA and glycine are also possibly involved in antinociception. Narcotics have been shown to produce analgesia when administered to the intrathecal or epidural spaces of humans. These routes are still experimental.

The place of clinical modification of transmitter system is discussed, but no conclusions or recommendations can be made at this early stage.
Drugs in Obstetric Anaesthesia
Authors: Morgan C. A. , Paull J.
Published: January 2019

From the anaesthetist's viewpoint, pharmacokinetics of pregnancy, drugs affecting uterine muscle tension and foetal effects of anaesthetic drugs are reviewed.
Vasodilator Drugs: Systemic and Regional Considerations
Authors: Brown M. J.
Published: January 2019

Therapeutic use of vasodilator drugs depends on the differential actions of these drugs on regional vascular beds. These differences include selective action on small and large arteries, differential potency on arterial and venous smooth muscle, and selectivity for autonomic receptors. The directly acting sodium nitroprusside and glyceryl trinitrate exemplify many of these differences as well as shared effects in the systemic, coronary and cerebral circulations.
Electromyographic and Mechanical Twitch Responses following Suxamethonium Administration
Authors: Shanks C. A. , Jarvis J. E.
Published: January 2019

Electromyographic and mechanical evoked twitch responses at the hand were observed simultaneously following suxamethonium. The intensity of neuromuscular blockade was assessed by comparison with their control heights of the responses obtained from both the force of thumb adduction and from the compound electromyogram (EMG). Surface electrodes placed dorsally over the lateral hand provided two EMG signals, one of which was assessed in terms of its amplitude, the other as the rectified and integrated energy envelope. While the mechanical and electrical events were roughly in agreement there was better conformity between the two EMG techniques in the assessment of paralysis.
Slow Dose Ketamine — A New Technique
Authors: Sher M. H.
Published: January 2019

A technique using a very low dose infusion of ketamine to provide intense analgesia without loss of consciousness as an alternative to general or regional anaesthesia during selected surgical operations is described and illustrated with three case reports.
Evaluation of a New Blood Warmer
Authors: Russell W. J.
Published: January 2019

Although some features are excellent, the Gorman-Rupp ‘dry heat’ warmer has serious weaknesses which render part of the electrical circuit susceptible to water. Its heating ability is quite good but not completely adequate at flows of 150 ml/min. It creates a moderate resistance to blood flow and flow by gravity would not be expected to exceed about 50 ml/min.
Atrax Robustus Envenomation
Authors: Fisher M. McD. , Carr G. A. , McGuinness R. , Warden J. C.
Published: January 2019

Two patients who developed massive pulmonary oedema, profound vasoconstriction and hypertension followed by hypotension after Atrax Robustus envenomation are described.

The pulmonary oedema is due to increased pulmonary capillary membrane permeability which may be due to neurogenic or toxic causes.

Use of artificial ventilation with high level PEEP, isoprenaline and high dose steroids allowed support of the patients during volume replacement with albumin. When the circulation was stable and airway frothing ceased, conventional dehydration therapy further improved lung function.

Both patients were discharged well.
Performance of Venturi Oxygen Delivery Devices
Authors: Fracchia G. , Torda T. A.
Published: January 2019

The oxygen blenders used in disposable oxygen masks from five manufacturers (Hudson, Inspiron, McGaw, Medishield and Vickers) were tested for delivered oxygen concentration and flow. In all concentration ranges the Medishield and McGaw were more accurate than the others. With some exceptions the flow output of these two devices was also adequate. The Medishield blenders which were tested over a wide range of oxygen inflows proved very stable in their delivered oxygen concentration.
Evaluation of Infrared Analysers used for Monitoring Waste Anaesthetic Gas Levels in Operating Theatres
Authors: Ilsley A. H. , Crea J. , Cousins M. J.
Published: January 2019

Several commercially available infrared analysers used to monitor levels of waste anaesthetic agent levels in operating theatres have been evaluated with respect to their specified accuracy, linearity and level of sensitivity.
A Trial of Meptazinol for the Relief of Pain after Abdominal Surgery
Authors: Gibbs John M. , Johnson Helen D.
Published: January 2019

Meptazinol is an opioid drug having mixed agonist-antagonist properties. Chemically it is a hexahydroazepine derivative. It has been used to provide postoperative analgesia1,2 for patients undergoing abdominal surgery but only in single dose studies. The drug is of particular interest in that the clinical impression of minimal ventilatory depression has been confirmed, 3 60 mg meptazinol showing less ventilatory depression than 10 mg of morphine. To test its efficacy in patients undergoing abdominal surgery and to assess the incidence of side effects, an open study was undertaken in 43 patients.
The Role of Atropine in Electroconvulsive Therapy
Authors: Wyant Gordon M. , MacDonald W. B.
Published: January 2019

The practice of preparing patients about to undergo electroshock treatment with atropine has been re-examined in the light of the great variety of practices which prevail both in terms of dose, route of administration and timing of the drug, as reported in the literature. By using patients as their own controls in the course of a series of treatments, it was determined that there are no appreciable differences between intravenous atropine given in different doses at different times and no atropine at all. Since no evidence was found that atropine contributes to cardiovascular stability or to consistent drying of secretions, and since its omission was not accompanied by untoward effects, it is suggested that the agent is not needed nor even necessarily desirable as a premedicant in electroshock therapy.
Paediatric Outpatient Surgery under General Anaesthesia
Authors: Rigg John R. A. , Dunn Geoffrey L. , Cameron Gordon S.
Published: January 2019

An innovative health care programme to provide anaesthesia and surgery to small children on an outpatient basis is described, together with the results of formal evaluations of the programme. It is concluded that, with attention to the education of the child and parents at a pre-anaesthetic clinic and the involvement of one parent with the induction and recovery of the child, the anaesthesia and surgery experience has negligible adverse psychological impact for the child, a positive influence on parental understanding and appreciation of the quality of anaesthesia care, in addition to a reduced incidence of cross infection and reduced cost to the health care system.
Predisposing Factors in Anaphylactoid Reactions to Anaesthetic Drugs in an Australian Population: The Role of Allergy, Atopy and Previous Anaesthesia
Authors: Laforest M. , More D. , Fisher M.
Published: January 2019

One thousand patients undergoing anaesthesia in an Australian hospital were assessed by questionnaire to determine the incidence of previous anaesthesia, allergy and atopy. The patients were compared with a British group and with 85 patients who had life-threatening anaphylactoid reactions. The Australian and British groups were not significantly different.

The Australian patients who had reactions showed a higher incidence of allergy, atopy, asthma and previous adverse reactions than the general population. The incidence was higher in females than males.

Although the incidence is higher in the group of patients who reacted, the incidence is not sufficiently great to make pretreatment of patients with a history of allergy or atopy a reasonable prophylactic manoeuvre.
Case Report — Bilateral Mandibular Coronoid Process Hyperplasia
Authors: Duffy B. L.
Published: January 2019

A rare case of bilateral hyperplasia of the mandibular coronoid processes is described in which blind intubation was performed using diethyl ether as the anaesthetic agent. Intra-oral surgery to remove the excess bone resulted in satisfactory mouth opening which was expected to improve further with physiotherapy.
Effect of Long-Term Continuous Infusion of Alfathesin on Clinical Biochemical and Haematological Parameters
Authors: Gibbs N. , Cameron P. D. , Thompson W. R. , Purser C. , Oh T. E.
Published: January 2019

Clinical biochemical and haematological parameters during long-term continuous infusion of alfathesin were studied in twelve neurosurgical patients who did not have multiple organ failure. Significant changes which were possibly caused by alfathesin were an alteration of blood film morphology, an elevation of plasma triglyceride and a reduction in plasma high-density lipids.
A Computer-Based Audit of Anaesthetic Registrar Training
Authors: Laurenson V. G. , Gibbs J. M.
Published: January 2019

A computerised summary of all anaesthetics administered by the North Canterbury Hospital Board's Department of Anaesthesia was used to examine the work patterns of registrars in the vocational training program over a two-year period. There was a considerable difference in the case load of some registrars even allowing for holidays and other leave. The exposure to surgical specialities and the degree of supervision were examined and problem areas identified. From a relatively simple data base it is possible to obtain information of value in the monitoring of a graduate training program.
Initial Assessment of Acute Haemorrhage
Authors: More David G.
Published: January 2019

The assessment of the patient with acute blood loss may be conveniently divided into three phases. The first involves the recognition that acute blood loss has occurred. Further assessment of the site and magnitude of the blood loss will continue in parallel with resuscitation.

The second phase of the assessment is the localising of the source or sources of bleeding to allow for control of continuing loss and to plan definitive therapy for the control of ongoing haemorrhage if necessary.

The third phase of assessment is to estimate the quantity of blood and fluid loss to allow for the rational planning of resuscitation. The third phase is divided into two sections: the first is the initial assessment of the magnitude of the loss, the second the ongoing assessment of the patient's status as resuscitation proceeds. Successful resuscitation depends on repeated assessment of the patient while treatment proceeds.
A Comparison of Morphine and Buprenorphine for Analgesia after Abdominal Surgery
Authors: Bradley J. P.
Published: January 2019

Eighty fit adults having elective abdominal hysterectomy or cholecystectomy received buprenorphine or morphine intravenously at the start of peritoneal closure, in a randomised double-blind trial. The anaesthetic sequence precluded the use of other narcotic analgesics. Pain scores were lower in patients who received buprenorphine, as were the cumulative numbers of patients withdrawn from the trial at each interval because of pain, statistical significance being achieved at all intervals from one to seven hours after administration. Unexpectedly, patients having the upper abdominal procedure were more likely to receive satisfactory analgesia than those having abdominal hysterectomy. Vomiting occurred more commonly after buprenorphine, and mean respiratory rates were slightly lower. However, the differences were not statistically significant. One patient with protracted drowsiness and slow respiratory rate after buprenorphine received naloxone. No serious side-effects were noted. Buprenorphine 4-6 μg/kg provided adequate postoperative analgesia of greater duration than could be achieved with morphine, and the potency of buprenorphine when administered in this way was at least 33 times that of morphine.
Management of Fifty Cases of Chest Injury with a Regimen of Epidural Bupivacaine and Morphine
Authors: Rankin A. P. N. , Comber R. E. H.
Published: January 2019

Epidural bupivacaine and morphine were administered to fifty patients who had suffered traumatic injuries to the chest. Forty-three of these patients made satisfactory recoveries without requiring any ventilatory support. Six patients were ventilated, one because of cardiovascular complications of myocardial infarction, two because of inadequate analgesia, and three because of respiratory failure. Three patients died. Serious side-effects were not common. One patient developed respiratory depression which required withdrawal of morphine, and one patient developed an epidural space infection.
Evaluation of the Transcutaneous Electrical Nerve Stimulator for Postoperative Analgesia following Cardiac Surgery
Authors: Navarathnam R. G. , Wang I. Y. S. , Thomas D. , Klineberg P. L.
Published: January 2019

The effectiveness of transcutaneous electrical nerve stimulation (TENS) in postoperative pain relief was assessed in this prospective randomised controlled study of 31 patients during the first 72 hours after cardiac surgery. Fourteen patients were given functioning TENS units, and seventeen patients were given non-functioning units. Postoperative pulmonary function tests, analgesic requirements and the incidence of atelectasis were compared in the two groups. Morphine requirement was significantly reduced on the second postoperative day and peak expiratory flow rates (PEFR) were significantly improved for the first two postoperative days in patients with functioning TENS units. The forced vital capacity (FVC) was significantly larger with functioning TENS units on the second postoperative day, but there were no other significant differences in forced expiratory volume in one second (FEV1) or forced vital capacity (FVC) values between the two groups. A questionnaire given to patients assessing their opinions of the effectiveness of the TENS unit for analgesia showed a placebo effect in some patients with non-functioning units. In summary, this study suggests that TENS may be of benefit in postoperative pain relief after cardiac surgery, especially on the second postoperative day.
Muscle Strength following Anaesthesia with Atracurium and Pancuronium
Authors: O'Connor M. , Russell W. J.
Published: January 2019

Postoperative recovery from muscle weakness was investigated by handgrip strength after general anaesthesia using short- and long-acting muscle relaxants. Handgrip strength was measured on four occasions, preoperatively, before and after premedication, and postoperatively, both as soon as the patient could sustain a five-second headlift and one hour later.

Twenty patients received either atracurium 0.6 mg/kg or pancuronium 0.1 mg/kg as part of a general anaesthetic technique with neostigmine reversal. Compared with their initial preoperative hand strengths, the two relaxant groups showed only an insignificant decrease in grip strength to 92% after premedication. Postoperatively when a five-second headlift was achieved, the patients in both groups were weak. The group given atracurium had a mean of 60% of their initial grip strength and those given pancuronium had a mean of 44%. This difference in strength was statistically significant from the initial level and from each other. However, there was no difference between the groups in the time interval from administering reversal to achieving a sustained headlift. One hour later in both groups grip strength was much better, within 80% of that seen after premedication in most patients, and no significant difference in grip strength was seen between the groups.

This study demonstrates that patients who receive relaxant anaesthesia have substantial muscle weakness in the recovery phase. When neostigmine reversal is used, pancuronium appears to have a similar return of voluntary muscle power to that seen with atracurium. The marked difference in elimination kinetics of these two relaxants seems to be of little importance when neostigmine reversal is used.
A Study of the Clinical Usefulness of Dobutamine Administered Orally
Authors: Noda Y. , Yazaki S. , Suzuki H. , Shibanoki S. , Ishikawa K.
Published: January 2019

Dobutamine 300 mg was administered orally to both healthy volunteers and to patients with circulatory failure. After the 300 mg dose of dobutamine, subjects were found to have a higher concentration of the drug in their plasma than the effective levels of 37.5 (SD 2.9) ng/ml (n = 5) normally seen during intravenous infusion of the clinically effective (5 μg/kg/min) dose. This increased concentration waned within 90 minutes.

A clinical effect of dobutamine on the circulation was observed in both the healthy volunteers and the patients. An increase in the cardiac index of the patients continued longer than 90 minutes. An unidentified substance was noticed on chromatography measuring plasma dobutamine concentrations, which may have contributed to the increased cardiac index, although its chemical formula could not be determined. The results suggest that the oral administration of dobutamine may be expected to have a long-lasting and significant therapeutic effect on patients with chronic circulatory failure.
The Cytokine Network in the Critically Ill
Authors: Bellomo R.
Published: January 2019

There is increasing experimental and clinical evidence that a number of cytokines play a major role in the response to injury and infection and in the development of organ damage in critically ill patients.

Tumour necrosis factor (TNF) is now proposed to be a key mediator of organ injury during sepsis. It is elevated early in the course of septic shock and high levels correlate with unfavourable outcome. In animals it can produce the effects of endotoxin. The prophylactic administration of anti-TNF antisera protects mice and rabbits from lethal effects of lipopolysaccharide.

Interleukin-1 (IL-1) is an endogenous pyrogen which induces leukocytosis and muscle catabolism. It causes hypotension and tachycardia by reducing smooth muscle contractility. IL-1 receptor blockers have been shown to diminish mortality in experimental endotoxic shock.

Interleukin-6 (IL-6) is a pyrogen and lymphocyte activator. It is the major stimulus to acute phase protein production by the liver.

A recently described neutrophil-activating peptide (Interleukin-8; IL-8) may be involved in the pathogenesis of ARDS. High blood levels of IL-8 have been found in patients with septic shock.

Platelet-derived growth factor (PDGF) has been shown to stimulate TNF production, leukocyte chemotaxis and pulmonary vasoconstriction in response to endotoxin. Other cytokines and growth factors have not yet been studied in critical illness.

The cytokine network can be either protective or damaging. Its activation during critical illness triggers complex and still poorly understood interactions. A better comprehension of its role in protection from infection and in the pathogenesis of multiple organ failure may allow therapeutic manipulations aimed at minimising adverse effects while retaining immunological protection.
Whitacre 22-gauge Pencil-point Needle for Spinal Anaesthesia. A Controlled Trial in 300 Young Orthopaedic Patients
Authors: Lynch J. , Arhelger S. , Krings-Ernst I. , Grond S. , Zech D.
Published: January 2019

In a prospective study of 300 young orthopaedic in-patients (< 40 years) given spinal anaesthesia through a 22-gauge Whitacre (n = 150) or a 25-gauge Quincke spinal needle (n = 150), we found a 5.3% and a 9.3% incidence of post-spinal headache (PSH) respectively. Females (10.6%) had a higher overall incidence of post-spinal headache than males (5.6%) with more than twice as many females being affected in the 25 than in the 22-gauge group (14.5% vs 6.1%). The average duration of post-spinal headache was less in the 22-gauge group (36 h vs 42.4 h) as was the incidence of severe headache. It is concluded that the Whitacre 22-gauge needle is more suited for spinal analgesia in young female patients due to its ease of handling and its lower incidence of post-spinal headache.
Plasma Catecholamine Levels following Topical Application versus Infiltration of Adrenaline for Nasal Surgery
Authors: van Hasselt C. A. , Low J. M. , Waldron J. , Gibb A. G. , Oh T. E.
Published: January 2019

Plasma catecholamine concentrations were measured after vasoconstrictor solutions were administered either by instillation (Moffett's method) or by submucosal infiltration in twenty patients undergoing elective nasal surgery.

Following infiltration with 4.4 ml of 1:80,000 adrenaline and 2% lignocaine, plasma adrenaline concentrations increased by 44.3 times to a peak of 9.9 nmol.l-1 (1813 pg.ml-1) within one minute. In contrast the peak level of adrenaline in the patients receiving Moffett's solution containing 1 ml of 1:1,000 adrenaline was 1.27 nmol.l-1 (232 pg.ml-1) occurring 10 minutes after instillation of the solution. The difference in the adrenaline concentrations between the groups was statistically significant (P < 0.01). The lack of sympathoneuronal response was confirmed by simultaneous measurements of plasma noradrenaline concentrations, which did not change significantly. The operative field was subjectively assessed to be better in the infiltrated patients and the mean operating time and measured blood loss were less in this same group of patients.
Preoperative Rectal Indomethacin for Analgesia after Laparoscopic Sterilisation
Authors: Crocker S. , Paech M.
Published: January 2019

A randomised, double-blind, placebo-controlled study was conducted among 56 day-case patients to determine the effect of the preoperative administration of rectal indomethacin on postoperative pain and opioid requirements after laparoscopic sterilisation.

Outcome in women receiving indomethacin did not differ significantly from the placebo group, but there was a trend to lower subjective pain scores, reduction in early postoperative pain assessed objectively and lower parenteral pethidine requirements in the first three hours postoperatively. Indomethacin did not appear either to cause side-effects or to significantly reduce morbidity from the other postoperative sequelae of laparoscopy.

Despite evidence for postoperative analgesic effect, the clinical benefits of premedication with rectal indomethacin were minor.
Oral Clonidine Pretreatment for Haemodynamic Stability during Craniotomy
Authors: Chadha R. , Padmanabhan V. , Joseph A. , Mohandas K.
Published: January 2019

We have studied the effect of clonidine pretreatment on cardiovascular responses to various stimuli during craniotomy. Fifty-eight patients (ASA Class I–II), scheduled for supratentorial surgery, were randomly given either oral clonidine, mean dose 3.6 μg/kg (n = 28), or oral diazepam, 0.2 mg/kg (n = 30), ninety to one hundred minutes before surgery. Anaesthesia was induced with thiopentone and maintained with nitrous oxide:oxygen, pentazocine and halothane. Pancuronium was used as a neuromuscular blocker. Mean arterial pressure and heart rate were recorded before and after several stimuli. In the clonidine group hypertensive response was significantly less on laryngoscopy (6.5% increases versus 11.2% in the diazepam group), intubation (9.2% versus 16.5%), Mayfield clamp application (14.5% versus 29.91%) and after skin infiltration with lignocaine-adrenaline solution (2.95% versus 5.42%). Heart rate response to laryngoscopy, intubation and skin infiltration was also significantly attenuated in the clonidine group. The sleep dose of thiopentone was smaller in patients pretreated with clonidine. Patients in the diazepam group required more medical intervention. No adverse effect occurred in any patient.
Transfusion: Morbidity and Mortality
Authors: Nicholls M. D.
Published: January 2019

Homologous, and to a significantly lesser extent, autologous blood transfusion is associated with definable and potentially serious risk. The increasing professional and public awareness has led to a critical evaluation of transfusion practices and a change in transfusion philosophy towards optimising transfusion therapy for individual patients. This involves the provision of the safest blood and the minimisation of homologous blood exposure. Autologous blood transfusion is not without risk as misidentification of patient or unit, bacterial contamination and volume overload can occur; consequently, the indications for the transfusion of autologous blood, as per homologous units, must be appropriate to the clinical circumstances. Appropriate transfusion criteria are being developed and lower haemoglobin levels are becoming accepted.

Transfusion-related mortality and morbidity data is infrequently reported. Ongoing transfusion surveillance programs have reported adverse reactions in 3.5% of transfusion episodes and fatalities have resulted from ABO-incompatible acute haemolytic transfusion reactions, most commonly with group O recipients of group A or B red cells. A significant number of such deaths are attributable to misidentification of patient or units and are preventable by obsessional attention to clerical details. The risks should be considered in the evaluation of the risk-benefit equation and in the resultant decision to administer blood.
Adverse Reactions to Plasma and Plasma Components
Authors: Isbister J. P.
Published: January 2019

Since the early days of plasma fractionation, plasma and derivatives have been identified as being responsible for a spectrum of mild to life-threatening reactions, but it is increasingly being recognised that plasma and its derivatives may be responsible for a wider range of reactions in recipients and more frequently than is commonly appreciated by clinicians. These reactions may be related to immunological differences between the donor and the recipient, either with the component being antigenic to the recipient or the plasma containing an antibody reacting with a recipient antigen. Secondly, there may be physicochemical characteristics of the plasma component such as temperature, additives, alterations due to preparative process and accumulation of metabolites or cellular release products on storage. All of these may in some patients be responsible for clinically significant reactions. This review presents a broad overview of the clinical presentations of recipient reactions due to plasma or plasma components and their underlying mechanisms. Unless there is an immediate or acute fulminant reaction to the infusion of plasma component, adverse effects of these blood products frequently go unrecognised and untreated. Some of the reactions, if undiagnosed, may have a significant effect on the outcome of the patient. There are also various preventative measures which may be taken in the preparation of blood products or their administration to minimise their potential adverse effects.
Complement (C3, C4) and C-reactive Protein Responses to Cardiopulmonary Bypass and Protamine Administration
Authors: Tulunay M. , Demiralp S. , Tastan S. , Akalin H. , Ozyurda U. , Corapcioglu T. , Akarsu E. S.
Published: January 2019

Complement activation has been deemed responsible for the damaging effects of cardiopulmonary bypass (CPB) in patients undergoing open heart surgery. We studied C3, C4 and C-reactive protein (CRP) in 22 patients undergoing CPB. In Group 1 (11 patients), protamine was given intravenously and in Group 2 (11 patients), via the aortic root after CPB. Significant decreases were observed in C3 and C4 during CPB in both groups indicating complement activation primarily by the classic pathway. Protamine did not lead to further activation of the complement system. In both groups, C3 levels gradually returned toward baseline within 24 hours but C4 levels were still lower than baseline 24 hours postoperatively. CPB and protamine administration did not cause any significant changes in CRP levels, but CRP increased abruptly 24 hours after operation. Although activation of complement system during CPB is expected to invoke an acute phase response, we conclude that this period is not long enough to induce an increased production of CRP in response to tissue injury or inflammation.
A Comparison between Direct and Calculated Oxygen Saturation in Intensive Care
Authors: Johnson P. A. , Bihari D. J. , Raper R. F. , Haughton M. A. , Fisher M. M. , Herkes R. G.
Published: January 2019

We investigated the discrepancy between calculated and spectrophotometrically determined oxygen saturation, and the corresponding effect of this difference on calculated oxygen uptake in 46 arterial-venous sample pairs from 28 critically ill patients.

The range of discrepancy between the two methods showed limits of agreement (mean ±2SD) of -2.26 to +0.70% for arterial samples, and - 5.52 to + 4.96% for the corresponding venous samples. The effect of this variation on oxygen uptake showed limits of agreement of -43.2 to 36.0 ml/min when the discrepancy between oxygen uptake, calculated using the direct measure of saturation, was compared to that using the derived value.

Multiple regression analysis showed that Pco2, temperature and 2,3 diphosphoglycerate were significantly related to saturation discrepancy with an R-squared value of 0.64 (P< 0.0001) for a subgroup of 25 venous samples. The precision of the Po2 electrode was also found to be a major contributory component to the discrepancies, particularly at venous Po2 values.

Thus the use of calculated oxygen saturation may result in clinically significant inaccuracies in the assessment of some oxygen flux variables.
The Influence of Adrenaline on Postoperative Analgesia after Subarachnoid Morphine
Authors: Paech M. J.
Published: January 2019

A randomised, double-blind study was conducted to investigate the postoperative effects of subarachnoid morphine, with or without adrenaline, after major gynaecological surgery. Seventy-five women having spinal anaesthesia combined with either sedation or general anaesthesia were randomised to receive subarachnoid morphine 0.25 mg with (group MA) or without (group M) adrenaline 200 ūg; or normal saline (group C). Groups M (n=22) and MA (n=25) differed significantly from control (n=23) with respect to the quality and duration of postoperative analgesia (P<0.0002) and to a higher incidence of pruritus (P<0.02). Groups were similar with respect to the incidence of other postoperative side-effects and respiratory data, although the latter showed a trend to less hypoxaemia in the control group. There was no significant difference in any outcome between groups MA and M. It was concluded that, under the study conditions in a post-gynaecological surgery population, the addition of adrenaline to subarachnoid morphine was of no benefit.
Enteral Feeding, Gastric Colonisation and Diarrhoea in the Critically Ill Patient: Is There a Relationship?
Authors: Levinson M. , Bryce A.
Published: January 2019

In this prospective study we aimed to determine whether there is any relationship between enteral feeding, gastric colonisation and diarrhoea in the critically ill patient. Sixty-two critically ill patients from an intensive care unit of a major teaching hospital, who satisfied the usual criteria for enteral feeding, were randomised to receive enteral feeding or not for three days followed by a second randomisation to enterally feed or not for three days. Diarrhoea was recorded and cultures taken of both gastric aspirates and stool.

There was no significant difference in the incidence of diarrhoea between the groups. Gastric colonisation was unrelated to feeding practice and to the development of diarrhoea.

We conclude that in the critically ill patient, enteral feeding does not cause or promote diarrhoea.
Prophylactic Paracetamol for Analgesia after Vaginal Termination of Pregnancy
Authors: Cade L. , Ashley J.
Published: January 2019

Many patients present to day surgery clinics for vaginal termination of pregnancy, a procedure which is frequently complicated by postoperative abdominal pain. We have assessed the efficacy of prophylactic paracetamol 1000 mg given orally shortly before surgery in 834 such patients in a randomised, placebo-controlled, double-blind study. Postoperative pain was reported in 35 % of patients, with no significant difference between treated and control patients. This negative finding was unexpected and is so far unexplained, given the usual efficacy of oral paracetamol in relieving this type of pain after it has occurred.
Spontaneous Clostridium Perfringens Lung Abscess Unresponsive to Penicillin
Authors: Baldwin L. , Henderson A. , Wright M. , Whitby M.
Published: January 2019

Clostridial necrotising pneumonia is a rare complication of aspiration, bronchial tumour or foreign body, pulmonary infarction, trauma and debilitating medical conditions. Although spontaneous clostridial pneumonia has been reported previously, close scrutiny of those case reports suggests that most of the patients had a recognised predisposing cause. We report a case of true spontaneous Clostridium perfringens pneumonia complicated by septic shock, pneumothorax and pulmonary necrosis. The patient responded poorly to conventional treatment with benzylpenicillin, and although the addition of metronidazole produced dramatic resolution of the sepsis, lobectomy was required to effect cure.
Epidural Catheter Insertion: The Effect of Saline Prior to Threading in Non-Obstetric Patients
Authors: Scott D. A. , Beilby D. S.
Published: January 2019

The effects of injecting normal saline 5 ml through the epidural needle before catheter passage on ease of catheterisation and incidence of certain complications were investigated in 189 non-obstetric patients. The use of saline had no effect on ease of catheterisation, with 84.2% of Group S patients (saline, n=95) and 88.3% of Group C patients (control, n = 94) having the difficulty of passing the catheter rated as “easy” (P=031). The incidence of complications was not affected by the use of saline. Paraesthesia occurred in 27.4% of Group S patients compared with 16.0% of Group C patients (P=0.08). Epidural venous cannulation occurred in 6.3% of Group S patients versus 11.7% of Group C patients (P=0.30). We conclude that the use of 5 ml of normal saline prior to catheter threading provides no significant benefit in improving the ease of catheterisation or decreasing the incidence of catheter complications.
The Influence of Obesity on the Relationship between Body Mass Index and the Distance to the Epidural Space from the Skin
Authors: Watts R. W.
Published: January 2019

This study confirms that distance to the epidural space from the skin at the L3–4 interspace is only moderately correlated with body mass index in obstetric patients.

A similar moderate linear correlation was found in the non-obstetric patients. However, in obese patients (BMI>25), distance to epidural space from the skin correlated poorly with body mass index.
A Review of Anaesthesia for Ruptured Abdominal Aortic Aneurysm with Special Emphasis on Preclamping Fluid Resuscitation
Authors: Brimacombe J. , Berry A.
Published: January 2019

Ruptured abdominal aortic aneurysm (RAAA) remains a critical emergency with an average hospital mortality of 50%. There has been no significant improvement in survival despite advances in anaesthesia, surgery and intensive care over the last 30 years. It is believed that early diagnosis, aggressive surgical management and meticulous attention to haemodynamic status and coagulation may improve survival, but this is unsubstantiated. Mortality is closely linked to the degree of preoperative hypotension and other related factors such as massive blood transfusion and cardiac arrest. Survival depends not only on the severity of rupture, but also the ability to compensate physiologically, and is linked to the premorbid state of the patient. Management priorities are dictated chiefly by the clinical signs and symptoms at presentation. There is controversy regarding the appropriate preoperative fluid regimen for RAAA.
Parental Attitudes to Presence at Induction of Paediatric Anaesthesia
Authors: Henderson M. A. , Baines D. B. , Overton J. H.
Published: January 2019

Previous studies of parental presence at induction of anaesthesia in children have examined parental reaction to being present and the benefits gained from their presence. This study was undertaken specifically to assess parents’ attitudes to being present at induction of their child's anaesthetic.

A total of 154 questionnaires were distributed over a two-week period to parents of children presenting to the Day Stay Unit for procedures requiring general anaesthesia. Eighty-eight percent would have liked to be present at induction. Only 41% of parents expected to be present and only 40% of parents were actually present for their child's induction. Of those parents present, 94% felt it helpful to their child, 65% helpful to themselves and 41% helpful to the anaesthetist. No-one felt their presence to have been unhelpful.

These results may provide an incentive for anaesthetists to review their current paediatric anaesthetic practices.
Quality Assessment in Personal Anaesthetic Practice
Authors: Boyle R. K.
Published: January 2019

Continuing education can improve anaesthetic practice if it is relevant to an individual's work and complications. A practice profile delineates the significance of untoward events. A personal audit of consecutive anaesthetics and associated complications is presented as a first step to checking one's competence over the course of years.
Difficult Intubation: An Analysis of 2000 Incident Reports
Authors: Williamson J. A. , Webb R. K. , Szekely S. , Gillies E. R. N. , Dreosti A. V.
Published: January 2019

The first 2000 incidents reported to the Australian Incident Monitoring Study were analysed with respect to the incidence and circumstances of problems with endotracheal intubation; 85 (4%) indicated difficulties with intubation. One third of these were emergency cases, one third involved an initially unassisted trainee and one fifth were outside normal working hours. Failure to predict a difficult intubation was reported in one third of the cases, with another quarter presenting serious difficulty despite preoperative prediction. Difficulties with ventilation were experienced in 1 in 7 of the 85 reports; there was one cardiac arrest, but no death. Endotracheal intubation was not achieved in one fifth of the cases.

The commonest complications reported amongst the 85 incidents were oesophageal intubation (18 cases), arterial desaturation (15 cases), and reflux of gastric contents (7 cases). Emergency trans-tracheal airways were required in 5 cases. Obesity, limited neck mobility and mouth opening, and inadequate assistance together accounted for two thirds of all the contributing factors. The most successful intubation aid in this series was a gum elastic bougie. A capnograph contributed to management in 28% and a pulse oximeter in 12% of the cases in which they were used. The most serious desaturations were associated with accidental oesophageal intubation.

These data suggest a lack of reliable preoperative assessment techniques and skills for the prediction of difficult intubations. They also suggest the need for a greater emphasis on ensuring that the necessary equipment is available, and on teaching and learning drills for difficult intubation and any associated difficulty with ventilation.
Problems with Ventilation: An Analysis of 2000 Incident Reports
Authors: Russell W. J. , Webb R. K. , Van Der Walt J. H. , Runciman W. B.
Published: January 2019

A review of the first 2000 incidents reported to the Australian Incident Monitoring Study found 317 incidents which involved problems with ventilation. The major portion (47%) were disconnections; 61% of these were detected by a monitor. Monitor detection was by a low circuit pressure alarm in 37% but this alarm failed to warn of non-ventilation in 12 incidents (in 6 because it was not switched “on” and in 6 because of a failure to detect the disconnection). Failure of detection was usually with ventilator bellows descending in expiration.

Complete failure to ventilate occurred in 143 incidents, most commonly because of a disconnection. Disconnection was associated, in one-third of the cases, with interference to the anaesthetic circuit by a third party and in nearly half with surgery on the head and neck. Leaks affected ventilation in 129 incidents, but in only 19 was ventilation totally lost; leaks associated with seal failure of the absorber were common. Misconnections occurred in 36 incidents, most commonly involving the scavenging system.

The frequency of a complete failure to check an anaesthetic machine was greater when an induction room was involved than when only the operating theatre was the site of the incident. These incidents suggest that meticulous checking and monitoring for failure of ventilation, preferably using at least two separate, self-activating systems is highly desirable. The Australian and New Zealand College of Anaesthetists’ policy on low circuit pressure alarms, oximetry and capnography is vindicated by these reports.
Problems with Regional Anaesthesia: An Analysis of 2000 Incident Reports
Authors: Fox M. A. L. , Webb R. K. , Singleton R. , Ludbrook G. , Runciman W. B.
Published: January 2019

There were 160 incidents associated with regional anaesthesia amongst the first 2000 incidents reported to the Australian Incident Monitoring Study. They were categorised into 6 groups; epidural anaesthesia (83), spinal anaesthesia (42), brachial plexus blocks (14), intravenous local anaesthesia (4), ocular blocks (3), and local infiltration (14). The largest single cause of incidents involved circulatory problems; these occurred in all the groups except brachial plexus block (30 cases of hypotension, 7 of arrythmias, 3 of cardiac arrest, 2 of hypertension and 1 of myocardial ischaemia). There were 24 drug errors, of which 10 involved the “wrong drug” and 4 “inappropriate use”. With the exception of these, all the remainder involved problems specific to regional anaesthesia: 26 inadvertent dural punctures; 19 failed or inadequate blocks; 14 dural puncture headaches (all cured by blood patches); 10 inadvertent total or high spinal blocks (of which 7 required artificial ventilation); 5 blocks on the wrong side or in the wrong patient; 3 late hypoxic incidents and a variety of miscellaneous problems. Three-quarters of all incidents occurred in the presence of an anaesthetist and over 90% in patients of ASA Groups I-III. Rapid recognition by the anaesthetist prevented many potentially life threatening events, and the only death was as a result of surgical bleeding.