bluuebunny/crossref_metadata_2025 huggingface dataset:
Recovery Room Incidents in the First 2000 Incident Reports
Authors: Van Der Walt J. H. , Webb R. K. , Osborne G. A. , Morgan C. , Mackay P.
Published: January 2019

Of the first 2000 incidents reported to the Australian Incident Monitoring Study 120 (6%) occurred in the recovery room after general, regional or local anaesthesia. Over two thirds (69%) of these involved the respiratory system, 19% were cardiovascular, 3 % involved the central nervous system and 9% were miscellaneous in nature. These recovery room incidents were associated with significantly more adverse outcomes (56%) than incidents in the operating theatre (24%). The types and relative frequencies of these recovery room incidents were similar to those of serious recovery complications in a recent analysis of closed malpractice claims; this suggests that incident monitoring may be useful in the study and prevention of recovery room complications.

Over three quarters (77%) of all recovery incidents (and 88% of respiratory incidents) were detected clinically; the remainder were first detected by a monitor. A theoretical analysis showed that over 95% of respiratory events, had they been allowed to evolve, would have been detected by pulse oximetry before organ damage occurred, emphasising the potential importance of pulse oximetry in reducing adverse outcome from any complication in the recovery ward which might be “missed” by clinical observation.

The findings of this study underline the importance of having an adequate number of trained recovery nursing staff supported by the availability of a pulse oximeter for each patient at least until the return of protective reflexes and the ability to maintain adequate arterial saturation has been established.
System Failure: An Analysis of 2000 Incident Reports
Authors: Runciman W. B. , Webb R. K. , Lee R. , Holland R.
Published: January 2019

Although 70–80% of problems have some component of human error, its overall contribution to many problems may be small; studies of complex systems have revealed that up to 85% are primarily due to deficiencies in the lay-out and processes of the system. The anaesthetist has to operate in a complex system; many problems originate from deficiencies in this system.

Information of relevance to system failure was extracted from the first 2000 incidents reported to the Australian Incident Monitoring Study (AIMS). A system-based deficiency directly contributed to one-quarter of problems (four-fifths if human factors are included), some aspect of the system minimized the adverse outcome in over half of all cases (four-fifths if human factors are included), and in two-thirds (three-quarters if human factors are included) a system-based strategy would have been helpful; the system was implicated in 90% of all incidents (97% if human factors are included).

Regardless of whether or not all human error should be regarded as part of the “system”, attempts to modify its incidence and nature have to emanate from the system. AIMS reporting pathways and the organizations involved in developing and implementing strategies to improve the system operate at four levels. Level I involves the use of AIMS reports by hospitals and group practices for audit at a local level. Level II involves AIMS participants sending forms to the AIMS central office; collated information is then sent back to contributors by newsletter. Level III involves interaction between AIMS and the major professional bodies and level IV interaction between AIMS, these bodies and a variety of national and international agencies. Over 100 topics were identified from the AIMS data for consideration at one or more of these levels. AIMS has the potential not only to play a vital practical role in the continued enhancement of the quality of anaesthetic practice, but also to provide a valuable resource for research at the increasingly important interface between human behaviour and complex systems.
Monoclonal Antibodies—Immunotherapy for the Critically Ill
Authors: Peake S.
Published: January 2019

Monoclonal antibodies (mAb) have revolutionised many areas of medicine, particularly research and diagnostics. Murine, human and humanised mAb have all been developed. The most important clinical applications to date have been in the fields of transplantation and oncology. Experimental and limited clinical trials suggest mAb are emerging as a new therapeutic strategy in the critically ill. Antibodies against a variety of bacteria or their products are potentially useful in gram-positive and gram-negative shock. Anti-cytokine and anti-neutrophil adhesion molecule mAb may be effective not only in septic shock but also in other conditions associated with acute inflammation and cytokine release, e.g., acid aspiration, ischaemia/reperfusion injury (myocardial infarction, haemorrhagic shock, aortic aneurysm repair). Antibodies inhibiting neutrophil adhesion may also be efficacious in asthma, pulmonary fibrosis, meningitis and cerebral malaria. The use of these and other mAb in intensive care is an exciting prospect and future clinical studies will determine the extent of their role in the management of the critically ill.
Cytokines in Plasma and Ultrafiltrate during Continuous Arteriovenous Haemofiltration
Authors: Tønnesen E. , Hansen M. B. , Höhndorf K. , Diamant M. , Bendtzen K. , Wanscher M. , Toft P.
Published: January 2019

Cytokines are considered to be important mediators in the pathophysiology of sepsis and septic shock. We investigated if continuous arteriovenous haemofiltration (CAVH) could be used to remove excessive amounts of the cytokines tumour necrosis factor-α (TNFα), interleukin (IL)-1α and IL-6 from peripheral blood in critically ill patients. Nine septic patients with renal failure were treated with CAVH. Ultrafiltrate and plasma were tested for cytokines by ELISA. All patients had detectable TNFα and IL-6 plasma levels, ranging from 10-750 pg/ml and 50-4,575 pg/ml, respectively. TNFα was removed by the ultrafiltrate with concentrations ranging from 10-1,000 pg/ml. The TNFα levels were significantly higher in the ultrafiltrate samples than in the corresponding plasma samples (P <0.003).

IL-6 was undetectable in the ultrafiltrate from five of the patients despite concomitant high plasma levels. IL-1α was detectable in both plasma and ultrafiltrate in four patients. All patients developed multi-organ failure and septic shock and seven died. It is concluded that TNFα and IL-1α but not IL-6 can be removed by CAVH in patients with sepsis.
The Effects of Providing Preoperative Statistical Anaesthetic-Risk Information
Authors: Inglis S. , Farnill D.
Published: January 2019

Are patients who are provided with details about anaesthesia risks on the eve of surgery better informed, and does the information increase their anxiety? Forty (ASA Class I or II) patients scheduled for surgery requiring general anaesthesia were randomly allocated to either a routine or a detailed information group. Levels of anxiety were assessed by the Spielberger State-Trait Anxiety Inventory. Actual knowledge of risks was assessed by a special visual analogue scale. Patients had experienced an average of five previous anaesthetics and so most patients in both groups knew the risks of common complications such as nausea and sore throat and were able to represent them accurately on the visual analogue scale. The detailed group, however, had gained more accurate knowledge of the likelihood of two rare complications, death (P <0.001) and serious tooth damage (P <0.05). Notwithstanding, there was no difference between the groups in anxiety. Thus, provision of detailed information about the risks of the complications of general anaesthesia did increase patients’ knowledge but did not increase patients’ levels of anxiety.
Outcome after Day-Care Surgery in a Major Teaching Hospital
Authors: Osborne G. A. , Rudkin G. E.
Published: January 2019

Outcome has been measured for 6000 consecutive procedures in a major public teaching hospital day surgery unit. The unanticipated hospital admission rate was 1.34% and surgery-related admissions (0.95%) exceeded those related to anaesthesia (0.13%). Perioperative complications related to surgery (1:105) were more frequent than those related to anaesthesia (1:176) and pre-existing medical problems (1:500). Anaesthesia-related complications were more frequent with general anaesthesia (1:114) than with local anaesthesia plus sedation (1:780) or regional anaesthesia (1:180). Recovery times after general anaesthesia were longer than after other anaesthetic techniques but did not correlate with patient age (r = 0.04; P = 0.02) and only weakly correlated with procedure duration (r = 0.21; P < 0.01). At early follow-up, 4.0% of patients had presented to a local medical practitioner and 3.1% to a hospital accident and emergency service, usually for minor problems. Take home analgesia was adequate for 95% of patients and 98.9% were happy with the day surgery service. Day surgery in a teaching hospital can provide satisfactory outcome, with low complication rates, high patient acceptance and low community support requirements after patient discharge.
Anaesthesia in Rural Queensland: Clinical Experience with the Flying Obstetric and Gynaecology Service
Authors: Cyna A. M.
Published: January 2019

The Flying Obstetric and Gynaecology (FOG) service visits 27 outback towns scattered over approximately one million square kilometres of western Queensland. The role and workload of an anaesthetist attached to the FOG Service and a prospective audit of 760 consecutive anaesthetics over a ten-month period are reported. Flying anaesthetists are in an ideal position to review standards of equipment, staffing levels, anaesthetic assistance in theatre as well as participate in both medical and nursing rural training programs. This ensures that deficiencies in anaesthetic related areas are identified and appropriate action taken. The challenge to rural practitioners must be to provide a service, of at least an equivalent standard to that of their metropolitan counterparts.
An Appraisal of Techniques for Administration of Gaseous Nitric Oxide
Authors: Tibballs J. , Hochmann M. , Carter B. , Osborne A.
Published: January 2019

Gaseous nitric oxide (NO) is a potent selective pulmonary vasodilator. When mixed with O2 for more than 10-15 minutes it forms toxic amounts of nitrogen dioxide (NO2). We describe two techniques to administer 20 parts per million (ppm) during mechanical ventilation. A technique using flows of NO and O2 at low pressure to drive a Siemens Servo 900C ventilator provided a constant inspired concentration of NO. Another technique in which NO was added to the inspiratory limb of a Siemens Servo 900C ventilator driven by high pressure oxygen provided a highly variable concentration (9-53 ppm) of inspired NO.
The Training/Examination Programme in Intensive Care, Australian and New Zealand College of Anaesthetists 1. Training
Authors: Clarke G. M. , Harrison G. A.
Published: January 2019

Unlike training for programmes in other countries which have published details of training programmes for Intensive Care Medicine, the training programme of the Australian and New Zealand College of Anaesthetists does not require certification in a primary specialty, although it is possible to combine training in Intensive Care and Anaesthetics. The lynchpin of the programme is the requirement that training can be undertaken in recognised posts in intensive care units which are approved by the College. Approval of the Unit requires evidence of appropriate supervision and teaching of trainees, sufficient number of admissions with a casemix suitable for the trainees’ learning needs and an adequate level of staff and equipment. The Units are assessed by physical inspection by assessors appointed by the College. The programme includes a Final Examination in Intensive Care.
Infusing Liquid Anaesthetics into a Closed Circuit
Authors: Weir H. M. , Kennedy R. R.
Published: January 2019

Closed circuit anaesthesia offers the user many advantages but practical problems impede its widespread use. When conventional vaporizers are employed adequate amounts of agent cannot be delivered into a totally closed circuit during the early stages of an anaesthetic. Direct injection, or infusion, of liquid anaesthetic into the circuit overcomes this problem.

The standard method for injecting agents directly into circuits is that described by Lowe and Ernst1. Their system can be approximated to a series of constant rate infusions, as is frequently done for propofol, and forms the basis of our technique.

For anaesthesia without nitrous oxide, liquid isoflurane should initially be infused into the circuit at a rate in ml/hr of 14 + 0.4 × weight in kg. After five minutes the infusion rate is reduced to 20% of this value. These rates are altered in the light of measured concentrations and clinical responses.
Vaporization of Isoflurane by Liquid Infusion
Authors: Thorpe C. M. , Kennedy R. R.
Published: January 2019

We investigated the vaporization of liquid isoflurane when infused directly into a circuit. Pooling of isoflurane occurred within the circuit tubing at infusion rates used during clinical practice when constant gas flows were used. Despite pooling, the concentration of isoflurane was linearly related to infusion rate. Cyclical gas flow, such as that seen in a circle system, increased vaporization so that pooling occurred only at the higher infusion rates used during the first five minutes of totally closed circuit anaesthesia. There were no major differences in pooling or the maximum concentration of isoflurane reached between 26 gauge needle and droplet administration of isoflurane: however the maximum concentration was reached more quickly by droplet administration. We conclude that direct infusion of liquid isoflurane into an anaesthetic circuit will result in complete vaporization during maintenance anaesthesia.
High Flow Closed Circuit Anaesthesia
Authors: Verkaaik A. P. K. , Van Dijk G.
Published: January 2019

We present an automatic closed circuit anaesthesia ventilator designed for routine clinical use. The ventilator combines the benefits of high flow systems and true closed circuits, without their disadvantages. The system can be used with any FiO2, with air or nitrous oxide as carrier gas. Servo controlled delivery of modern volatile anaesthetics is regulated on endtidal value. The time constant for increase or decrease of concentrations is only a few minutes. There is no need to open the system at any time, nor is it necessary to increase the fresh gas flow. An automatic flush procedure prevents accumulation of unwanted gases. Operation is as easy as contemporary non-closed circuit ventilators. With this machine, closed circuit anaesthesia is possible from the beginning to the end of the procedure.
Control of Carbon Dioxide Levels during Neuroanaesthesia: Current Practice and an Appraisal of our Reliance upon Capnography
Authors: Isert P.
Published: January 2019

With the widespread availability of capnography, many anaesthetists have swung away from formally verifying hypocapnia by intraoperative arterial blood gas analysis and, instead, have come to rely upon capnography as an acceptable and constant predictor of arterial CO2 tension (PaCO2) during neurosurgery. However, the nature of the arterial-endtidal CO2 gradient is complex, and is frequently unexpectedly large, or even negative. The importance of close intraoperative CO2 control during neurosurgery—more specifically, routine hyperventilation, and our reliance upon capnography to guide intraoperative management—is reappraised. There is a growing appreciation of the adverse effects of hyperventilation and hypocarbia, especially upon abnormal or ischaemic brain, and it is clear that capnography alone cannot be used to confidently predict the true PaCO2 during neuroanaesthesia.
Anaesthesia for Laser Prostatectomy
Authors: Costello T. G. , Costello A. J.
Published: January 2019

A retrospective review was undertaken to examine current anaesthetic practice in a single institution for the management of patients undergoing laser ablation of the prostate for benign prostatic hypertrophy at St Vincent's Private Hospital, Melbourne.

Two groups of patients (totalling 72) were identified, one undergoing the surgery with a regional anaesthetic technique and a smaller group on full anticoagulant therapy for associated medical problems where general anaesthesia was preferred.
Postoperative Epidural Fentanyl Infusion—is the Addition of 0.1% Bupivacaine of Benefit?
Authors: Paech M. J. , Westmore M. D.
Published: January 2019

A randomised, double-blind controlled clinical trial was conducted in 90 women scheduled for major abdominal gynaecological oncology surgery to determine the effect of adding 0.1% plain bupivacaine to a thoracic epidural fentanyl infusion. Following combined epidural and general anaesthesia, patients were randomised to receive epidural fentanyl 10 μg/ml, with (group FB) or without (group F) bupivacaine. After an initial 50 μg bolus of fentanyl, infusion rate was adjusted according to need between 2 and 10 ml/hr for 48 hours.

The two groups (n = 40) were similar with regard to age, weight and preoperative status. Analgesia both at rest and with movement were significantly better in group FB (P < 0.0001) during the first 24 hours postoperatively, the greatest difference occurring in the 4 to 16 hour period. There was no significant difference between groups from 24 to 48 hours postoperatively. Fentanyl utilisation was significantly lower in group FB (median 41 versus 53 μg/hr, P <0.001), although clinically the fentanyl dose-sparing effect of bupivacaine was small and did not reduce opioid-induced side-effects. There was no significant difference between groups with respect to side-effects or lower limb weakness, although fewer patients in group FB could be mobilised on the morning of the first postoperative day (P <0.01). Nevertherless, all study patients were ambulant by the same afternoon.

We concluded that, in this patient population, the addition of 0.1% bupivacaine to a thoracic epidural fentanyl infusion was beneficial in the early postoperative period.
Factors Affecting Outcome following Cardiopulmonary Resuscitation
Authors: So H. Y. , Buckley T. A. , Oh T. E.
Published: January 2019

Many patients who receive cardiopulmonary resuscitation (CPR) for cardiac arrest do not survive to leave hospital. Factors associated with adverse outcomes include unwitnessed cardiac arrest in general wards, particularly at night, prolonged resuscitation, asystole, associated disorders (e.g. sepsis, malignancy, renal failure, and left ventricular dysfunction), absent pupillary responses, hypoxaemia, low PetCO2 during resuscitation, and severe acid base imbalance. Outside hospitals, cardiac arrests result in more favourable outcomes if they occur at work, and bystander CPR and early defibrillation are initiated. On admission to ICU, likely predictors of death or severe neurological disability include prolonged coma, impaired brainstem reflexes, and persistent convulsions. Experience with cerebrospinal fluid enzymes and electrophysiological measurements is limited. Multivariate scoring systems are not sufficiently reliable. The importance of hyperglycaemia, the required level of CPR training, and the appropriateness of responding to some cases, remain debatable.
Patterns of Coagulopathy during Liver Transplantation: Experience with the First 75 Cases using Thrombelastography
Authors: Mcnicol P. L. , Liu G. , Harley I. D. , Mccall P. R. , Przybylowski G. M. , Bowkett J. , Angus P. W. , Hardy K. J. , Jones R. M.
Published: January 2019

Using both conventional laboratory clotting profile and thrombelastography, coagulation status was monitored intraoperatively during liver transplantation in the first 75 cases performed at the Austin Hospital between June 1988 and October 1992.

Superimposed on a baseline coagulopathy due to liver disease is a specific pattern of coagulation disturbance which occurs during a liver transplant. Fibrinolysis occurs in the anhepatic stage, worsens with early reperfusion and then spontaneously resolves. In addition reperfusion is associated with a transient clotting defect. If blood loss is excessive, coagulopathy due to massive transfusion may compound the situation.

Thrombelastography is a measurement technique allowing rapid on-site assessment of functional clotting status’. It is particularly useful in liver transplant surgery. In combination with clinical bleeding assessment it facilitates selective use of component therapy (fresh frozen plasma, platelets and cryoprecipitate) and specific drug treatment only when it is appropriate. It also acts as a liver function test, being especially useful in assessing the graft after reperfusion.
Blood Loss and Transfusion Requirements in Liver Transplantation: Experience with the First 75 Cases
Authors: Mcnicol P. L. , Liu G. , Harley I. D. , Mccall P. R. , Przybylowski G. M. , Bowkett J. , Angus P. W. , Hardy K. J. , Jones R. M.
Published: January 2019

The blood loss data and transfusion requirements including blood bank, salvaged washed red cells, fresh frozen plasma and cryoprecipitate were analysed for the first 75 cases of liver transplantation performed at the Austin Hospital between June 1988 and October 1992.

The mean blood loss was 8.8 litres (standard deviation 14.1) with a median value of 4.0 litres. Blood product use expressed as mean number of units (SD) was bank red blood cells 7.1 (12.7), washed red blood cells 3.9 (5.9), fresh frozen plasma 7.1 (9.1), platelets 5.1 (7.4), and cryoprecipitate 1.7 (5.1).

These results demonstrate that liver transplantation can be performed without imposing excessive demands on blood transfusion services. Management should include surgical techniques to minimize bleeding and use of autologous transfusion. Use of component therapy (FFP, platelets and cryoprecipitate) should not be empirical. It should be selective on the basis of clinical bleeding assessment and guided by results of the laboratory coagulation profile and changes in thrombelastographic (TEG) parameters.
P6 Acupressure and Nausea and Vomiting after Gynaecological Surgery
Authors: Allen D. L. , Kitching A. J. , Nagle C.
Published: January 2019

We studied the effect of P6 acupressure on 46 women undergoing laparotomy for major gynaecological surgery who received patient-controlled analgesia. Half the patients received acupressure at the P6 site, the remainder received acupressure at a “sham” site. There was a reduction in the requests for anti-emetic therapy in the group receiving P6 acupressure but there was no difference in the incidence of nausea and vomiting. There was no difference in total morphine consumption between the two groups.
The Incendiary Characteristics of the Laryngeal and Reinforced Laryngeal Mask Airway to CO2 Laser Strike—A Comparison with Two Polyvinyl Chloride Tracheal Tubes
Authors: Brimacombe J.
Published: January 2019

The incendiary characteristics of the laryngeal and reinforced laryngeal mask airway to the CO2 laser have been compared with two polyvinyl chloride tracheal tubes. Three different power densities (2.35, 4.7 and 9.8 × 103 watt/cm2) were used, with either oxygen or a 30% oxygen/70% nitrous oxide mixture flowing down the tube. The laryngeal mask airway (and reinforced model) was shown to be more resistant than the polyvinyl chloride tracheal tubes. The laryngeal mask tube could not be ignited at a power density of 2.25 × 103 watt/cm2 after five minutes, although penetration occurred in 20-30 seconds. A layer of silica ash built up at the impact site and protected the underlying tube. The laryngeal mask airway cuff was penetrated at 3 to 5 seconds. At this power density the polyvinyl chloride tube ignited in 2 to 8 seconds and the cuff was penetrated in 0.1 seconds. At the highest power density the tubes of all airways ignited within 0.2 seconds. The possibilities for improving the incendiary characteristics of the laryngeal mask airway are discussed.
A Comparison of Syringes to Collect Blood for Analysis of Gases, Electrolytes and Glucose
Authors: Carter B. G. , Tibballs J. , Hochmann M. , Osborne A. , Chiriano A. , Murray G.
Published: January 2019

We studied the interchangeability of two blood gas syringes (Johns, Hardie Health Care Products Pty Ltd and Marksman, Martell Medical Products Inc) for the collection of blood for the analysis of PCO2, PO2, pH, sodium, potassium and glucose in 71 intensive care unit patients. The interchangeability of these two syringes with a specially designed syringe (Radiometer, Radiometer A/S) for the collection of blood for the analysis of ionized calcium was also studied. Analysis of pH, sodium, potassium and glucose showed no clinically significant differences between samples collected with Johns and Marksman syringes. However, differences in PCO2 and PO2 in samples collected with these syringes may be clinically significant if the PO2 is less than 100 mmHg. There were no clinically significant differences in ionized calcium levels in blood samples collected with Johns, Marksman and Radiometer syringes. We conclude that Johns and Marksman syringes are interchangeable for the collection of blood for the analysis of PCO2, PO2, pH, sodium, potassium and glucose and they are also interchangeable with Radiometer syringes for the collection of blood for ionized calcium analysis.
An Overview of Transplantation in Australia
Authors: Mcbride M. , Chapman J. R.
Published: January 2019

Organ donation in Australia has permitted transplantation of the kidneys, heart, lung, pancreas, liver and cornea. Each of these programs has successfully provided life and rehabilitation to Australians with end-stage failure of one or more organs. The programs are supported by an infrastructure of donor co-ordinators, matching and allocation procedures and national co-operative registries, which record and publish the outcome of each form of transplant. Four national organizations work to promote transplantation: the Transplantation Society of Australia and New Zealand; the Australasian Transplant Co-ordinators’ Association; the Australian Kidney Foundation; and the Australian Co-ordinating Committee for Organ Registries and Donation. Australian donation rates are lower than in many, but not all, comparable developed democracies, however utilization of those donor offers is high, leading to 698 organ transplants being performed in 1993.
Anaesthesia for Laser Pharyngoplasty—A Comparison of the Tracheal Tube with the Reinforced Laryngeal Mask Airway
Authors: Sher M. , Brimacombe J. , Laing D.
Published: January 2019

A common cause of snoring is palatal flutter which occurs when turbulent airflow causes the flexible soft palate to flutter. Surgical correction involves either removal of the soft palate or a reduction in its flexibility. Laser pharyngoplasty is a new surgical procedure designed to stiffen the soft palate. It presents a unique combination of problems for the anaesthetist. In this paper we describe the evolution of the anaesthetic technique for laser pharyngoplasty and analyse the results of the first 165 cases. Points of particular interest include the use of the reinforced laryngeal mask airway compared with the tracheal tube and late onset pain.
Modulating Effects of Lignocaine on Propofol
Authors: Tham C. S. , Khoo S. T.
Published: January 2019

Pain is a well known complication of propofol injection. Premixing with lignocaine 0.1 mg.kg−1 and injection into a large forearm vein has been recommended. The amount of lignocaine to be added is often empirical when the vein on the dorsum of the hand is used. In this study we attempt to determine the optimal amount of lignocaine necessary to reduce pain when propofol is injected into a hand vein. Our study shows that a propofol emulsion containing 0.05% lignocaine is effective in reducing the incidence of propofol injection pain. The addition of lignocaine also reduces the incidence of excitatory effects. Increasing the dosage of lignocaine above 0.05% does not improve the results.
Ketorolac or Pethidine for Analgesia after Elective Laparoscopic Sterilization
Authors: Cade L. , Kakulas P.
Published: January 2019

Laparoscopic sterilization is commonly performed as a day surgery procedure despite difficulties in providing adequate postoperative analgesia for all patients. We have examined the analgesic utility of intramuscular ketorolac in this setting by comparing it with intramuscular pethidine, both given after induction in a randomized, double-blind study in sixty such patients. Although the analgesic effects of the two drugs were comparable in the immediate postoperative period, ketorolac provided significantly better analgesia four hours after surgery (pain score of 2.7 v. 4.2, P=0.006). The recovery times taken to awake, to ambulate and for discharge were all significantly shorter after ketorolac (4.6 v. 8.8 min, P=0.01; 178 v. 260 min, P=0.0005; 242 v. 320 min, P=0.02), and the unplanned admission rate was also significantly less after ketorolac (7% v. 33%, P=0.01). Ketorolac appears to be a useful supplement for analgesia after laparoscopic sterilization, providing improved analgesia as well as decreased recovery time and fewer unplanned admissions.
Rationalizing Venepuncture Pain: Comparison of Lignocaine Injection, Butterfly (21 Gauge and 23 Gauge) and Venflon (20 Gauge)
Authors: Van Den Berg A. A. , Rama Prabhu N. V.
Published: January 2019

Two hundred and seventy-eight patients scheduled for all types of surgery and premedicated with diazepam and metoclopramide were randomly allocated to one of four groups to compare the relative pain of an injection of 0.25 ml of lignocaine 1% via a 25 gauge needle with the pain of the siting of a 21 gauge Butterfly (Abbott), 23 gauge Butterfly or a 20 gauge Venflon (Vigo Spectramed). The injection of lignocaine and insertion of the 23 gauge Butterfly were associated with the least complaints of pain and least observed responses to pain. The 21 gauge Butterfly and 20 gauge Venflon were associated with complaints of greater pain and more pain responses. We conclude that a pre-cannulation injection of lignocaine causes minimal discomfort and is the most appropriate means of reducing the discomfort of venous cannulation when not using skin penetrating analgesic creams.
Postoperative Vomiting in Children
Authors: Kermode J. , Walker S. , Webb I.
Published: January 2019

A survey of the incidence of postoperative vomiting in 1476 children was conducted over a two-month period as part of our quality assurance programme. The incidence of vomiting was 24%, and was highest in children over three years of age and in those receiving opioids. The incidence is lower than that recorded in an earlier (1981) survey in our hospital. Changes in anaesthetic practices may have contributed to this decrease.
Is There a Role for Selective Decontamination of the Digestive Tract in Primarily Infected Patients in the ICU?
Authors: Hammond J. M. J. , Potgieter P. D.
Published: January 2019

The role of selective decontamination of the digestive tract (SDD) for the prevention of nosocomial infection in critically ill patients remains controversial, and the efficacy of this technique in patients who are already infected on presentation to the intensive care unit has not previously been assessed.

We performed a double-blind randomized placebo controlled trial of SDD (parenteral cefotaxime, six-hourly oral and enteral polymyxin E, tobramycin, and amphotericin B vs placebo) for all infected patients presenting to the ICU requiring mechanical ventilation for more than 48 hours and ICU stay of more than 5 days. Daily clinical and microbiological monitoring for secondary infection was undertaken until hospital discharge.

In all, 59 selective decontamination and 76 placebo fully comparable patients fulfilled criteria for enrolment and analysis (APACHE II 15.2 vs 15.1). The number of patients receiving SDD who developed nosocomial infections was significantly reduced (P = 0.048), and there were no infections caused by the enterobacteriaceae or Candida spp in this group. No difference in ICU (17.5 vs 18.8 days) or hospital stay (32.7 vs 34.2 days) or mortality (17% vs 22.3%) was shown.

Critically ill, primarily infected patients are protected from nosocomial infection by the use of SDD.
Breathing Systems Reclassified
Authors: Miller D. M.
Published: January 2019

The purpose of reclassifying breathing systems is to enhance understanding by relating structure to function. A previous classification1 which appears to fulfill this objective is updated to include recent developments in a newly named group of systems called “displacement afferent reservoir” (DAR) breathing systems. A classification table allows for quick comparison and shows that, of the non-absorber systems, the DAR group has the best characteristics of fresh gas utilization.
A Comparative Evaluation of Pressure-Triggering and Flow-Triggering in Pressure Support Ventilation (PSV) for Neonates Using an Animal Model
Authors: Uchiyama A. , Imanaka H. , Taenaka N. , Nakano S. , Fujino Y. , Yoshiya I.
Published: January 2019

The triggering system in pressure support ventilation needs to respond rapidly, especially in neonates. The aim of this study was to compare the effects of flow-triggered and pressure-triggered pressure support ventilation on neonatal mechanical ventilation using an animal model. Respiratory flow, airway pressure, oesophageal pressure, and diaphragmatic electromyogram were measured during pressure support ventilation in five anaesthetized rabbits. The animals were connected to a VIPBIRD (Bird, U.S.A.) (CPAP mode, pressure support ventilation, 5 cm H2O) and PEEP 0 cm H2O). Flow-triggering sensitivity was set at 0.21/min, 0.51/min, 1.011/min, or 1.51/min. Pressure-triggering sensitivity was set at −1.0 cm H2O. Shorter trigger delay and longer pressure support time were observed in flow-triggering. There was also less diaphragmatic activity in flow-triggering as evidenced by the amplitude of integrated diaphragmatic electromyogram and negative deflection of oesophageal pressure. The findings suggest that flow-triggering will prove superior to pressure-triggering in pressure support ventilation for neonates.
Low Gastric Intramucosal pH: Incidence and Significance in Intensive Care Patients
Authors: Trinder T. J. , Lavery G. G. , Fee J. P. H. , Lowry K. G.
Published: January 2019

Monitoring of gastric intramucosal pH (pHi) is advocated in critical illness to detect tissue acidosis due to regional hypoperfusion. However, the number of patients who may benefit from such monitoring remains unclear and the relationship between low pHi and outcome requires further definition. Sixty consecutive patients with Acute Physiology and Chronic Health Evaluation (APACHE II) scores <30 were studied throughout ICU stay to investigate the incidence of low pHi (<7.32 for > 1 hour), its relationship to outcome, and temporally associated clinical events. pHi was measured 2 to 6 hours post-ICU, admission and 8-hourly thereafter. Forty-four patients (73%) exhibited low pHi Fourteen patients died in ICU with 13 deaths occurring in the low pHi group (P=0.05). length of ICU stay was greater in the low pHi group (P=0.02). The development of low pHi was temporally associated with maximal sepsis score, weaning from assisted ventilation and commencement of enteral feeding.
The Use of “Quality-Adjusted Life Years” (QALYs) to Evaluate Treatment in Intensive Care
Authors: Kerridge R. K. , Glasziou P. P. , Hillman K. M.
Published: January 2019

This study examines the feasibility of using Quality-Adjusted Life Years (QALYs) to assess patient outcome and the economic justification of treatment in an Intensive Care Unit (ICU).

248 patients were followed for three years after admission. Survival and quality of life for each patient was evaluated. Outcome for each patient was quantified in discounted Quality-Adjusted Life Years (dQALYs). The economic justification of treatment was evaluated by comparing the total and marginal cost per dQALY for this patient group with the published cost per QALY for other medical interventions.

150 patients were alive after three years. Quality of life for most longterm survivors was good. Patient outcome (QALYs) was greatest for asthma and trauma patients, and least for cardiogenic pulmonary oedema. The tentative estimated cost- effectiveness of treatment varied from AUD $297 per QALY for asthma to AUD $2323 per QALY for patients with pulmonary oedema. This compares favourably with many preventative and non-acute medical treatments.

Although the methodology is developmental, the measurement of patient outcome using QALYs appears to be feasible in a general hospital ICU.
Anaesthesia for Adults with Cystic Fibrosis
Authors: Weeks A. M. , Buckland M. R.
Published: January 2019

Cystic fibrosis is an autosomal recessive disorder which affects one in 2500 live births. It is a multisystem disease and has a variety of presentations. The major clinical features affect the gastrointestinal and respiratory tracts. Severe respiratory disease, diabetes and gastroesophageal reflux are common features of concern to anaesthetists. Improved care of young patients has allowed many to survive into adulthood. Lung transplantation has significantly improved the outlook for many patients. At Alfred Hospital, 74 patients with cystic fibrosis underwent 149 procedures from January 1978 to January 1994, with a mortality of 0.6% (95% CI 0.4%-0.8%). This retrospective cohort study describes the anaesthetic management and perioperative care of these patients. Most of the anaesthetics were for procedures related to cystic fibrosis but 12% were for unrelated conditions. Cystic fibrosis related procedures include diagnostic, venous access, enteral feeding procedures, treatment of complications of cystic fibrosis and lung transplantation. Despite extremely poor respiratory function, these patients can be managed with acceptably low postoperative mortality (1%). Pre- and postoperative care must be directed towards optimal clearance of viscous respiratory secretions. Procedures need to be planned so that optimal care can be given by each member of the team caring for cystic fibrosis patients.
A Review of Anatomical and Immunological Links between Epidural Morphine and Herpes Simplex Labialis in Obstetric Patients
Authors: Boyle R. K.
Published: January 2019

The anatomical basis for facial itch after epidural morphone is outlined. CNS nuclear events which reactivate latent herpes simplex and immune inhibition resulting in maternal mouth vesicles or neonatal infections are described. Morphine is hypothesized to affect these processes and facial itch is only a marker, not a trigger of this trigeminal opioid activity.
Herpes Simplex Labialis after Epidural or Parenteral Morphine: A Randomized Prospective Trial in an Australian Obstetric Population
Authors: Boyle R. K.
Published: January 2019

A prospective randomized controlled trial was conducted in women undergoing emergency and elective caesarean section to determine whether epidural morphine predisposes to postoperative herpes simplex labialis and whether the risk is increased or decreased by previous oral herpes or pruritus. Following cannulation of the epidural space, analgesia for labour and/or caesarean section was induced in two groups of similar age, parity, preoperative status and anaesthetic. According to tables of random numbers, 386 were allocated to receive parenteral morphine and 425 to receive epidural morphine. Postoperative herpes labialis was diagnosed by laboratory culture and microscopy. Patients who received epidural morphine were 11.5 times (95% CI 2.6–49.4) more likely than the parenteral morphine group to suffer herpes labialis. A past history of oral herpes increased the risk of herpes labialis by 8.6 times (95 % CI 3.3–22.0). When the influence of past herpes infection and route of morphine were taken into account, no separate association between pruritus and herpex simplex labialis could be demonstrated.
A Double-Blind Randomized Prospective Study Comparing Ondansetron with Droperidol in the Prevention of Emesis following Strabismus Surgery
Authors: Davis A. , Krige S. , Moyes D.
Published: January 2019

A prospective double-blind study was conducted to compare the anti-emetic efficacy of ondansetron and droperidol in preventing postoperative emesis following strabismus surgery. A sample size of 213 patients was divided into three equal groups to receive ondansetron 150 μg/kg (Group A), ondansetron 75 μg/kg (Group B), or droperidol 75 fig/kg (Group C). All patients received a standardized anaesthetic technique. All episodes of emesis, recovery time, and time to tolerating oral fluids were recorded.

The incidence of emesis during 24 hours was Groups A and B 19.7%, and Group C 28.2%. The lower incidence of emesis recorded by the ondansetron groups compared with the droperidol group was not statistically significant. Ondansetron at 75 μg/kg was as effective as 150 μg/kg in reducing emesis when compared with droperidol.

Mean time to discharge from the recovery room was 75.3 minutes (Group A), 44.4 minutes (Group B), and 41.0 minutes (Group C). The mean time to tolerating oral fluids was 356.5 minutes (Group A), 402.8 minutes (Group B), and 378.1 minutes (Group C). There was no statistical difference in discharge times from recovery or time to tolerating oral fluids in any of the three groups.
The Efficacy of Adding a Continuous Intravenous Morphine Infusion to Patient-Controlled Analgesia (PCA) in Abdominal Surgery
Authors: Dawson P. J. , Libreri F. C. , Jones D. J. , Libreri G. , Bjorkstein A. R. , Royse C. F.
Published: January 2019

The effect of adding a continuous infusion of morphine 1 mg/hr to patient-controlled intravenous analgesia was studied in a randomized double-blind trial. Ninety-six patients scheduled for abdominal surgery were enrolled; 38 received PCA and continuous infusion (PCA + C), 45 received PCA alone and 13 were excluded because of protocol violations. PCA was delivered via an ABBOTT 4200 pump with settings of morphine 1 mg bolus and five-minute lockout in both groups. A separate pump delivered a continuous infusion of morphine 1 mg/ml (PCA + C) or 9% normal saline (PCA) at 1 ml/hr for three postoperative days. Pain was assessed by hourly verbal pain scores (VPS) and daily visual analog pain scores at rest and on movement (VASrest, VASmove). PCA delivered morphine and the demand to delivery ratio (D/D ratio) were used as indirect indicators of pain. These were assessed during daytime (0800–2200 hours), sleep (2200–0500 hours) and on first waking (0500–0800 hours).

Patient demographics were similar. Patients receiving a continuous infusion had lower pain scores during the first 24 hours but not thereafter (VPS P=0.04, VASmove P=0.02). The PCA group delivered more PCA morphine during 0500–0800 hours and 0800–2200 hours on the first day only. There was no significant difference in the D/D ratio for any time period during the three days. Total morphine delivery was greater in the PCA + C group on the second and third postoperative days (P= 0.009 and P=0.0001 respectively). The incidence of respiratory depression and the total number of complications were significantly higher in those receiving continuous infusion (P=0.04 and P=0.011 respectively.)

Adding a continuous morphine infusion of 1 mg/hr to the described PCA settings for three days following abdominal surgery improved analgesia during the first 24 hours but was associated with a greater incidence of complications.
Clincial Experience with Patient-Controlled and Staff-Administered Intermittent Bolus Epidural Analgesia in Labour
Authors: Paech M. J. , Pavy T. J. G. , Sims C. , Westmore M. D. , Storey J. M. , White C.
Published: January 2019

A prospective randomized study was Performed to detail clinical experience with both patient-controlled epidural analgesia (PCEA) and midwife-administered intermittent bolus (IB) epidural analgesia during labour, under the conditions pertaining in a busy obstetric delivery unit. Both methods used 0.125% bupivacaine plus fentanyl, and similar rescue supplementation although management decisions related to epidural analgesia were made principally by attending midwives

One hundred and ninety-eight women were recruited and data analysed from 167 (PCEA n = 82 IB n=85) The groups were demographically similar. Median hourly pain scores, ratings of analgesia and satisfaction did not differ Maximum pain scores were significantly higher in those receiving IB epidural analgesia (P<0.05). The PCEA group had a significantly higher rate of supplementation and bupivacaine use (P<0.01), and a longer duration of the second stage of labour (P<0.03) The relative risk of instrumental delivery with PCEA versus the IB method was 1.57 (CI 1.07–2.38)

Experience within our unit with PCEA is contrasted with that of IB epidural analgesia, the method most commonly used; and with that of controlled trials comparing these two methods.
Effect of Propofol Infusion on the Endocrine Response to Cardiac Surgery
Authors: Ng A. , Tan S. S. W. , Lee H. S. , Chew S. L.
Published: January 2019

The effect of propofol infusion on the stress response was studied in patients undergoing coronary artery bypass graft (CABG). Ten patients received propofol infusion during cardiopulmonary bypass (CPB) and ten controls received diazepam. Blood levels of Cortisol, adrenaline and noradrenaline were sampled. There was a significant reduction in all three hormones (P<0.05) in the study group. In addition, the amount of sodium nitroprusside used during CPB was significantly reduced (P<0.05).
Accuracy of the Tonometric Function of Recycled Gastric Tonometer Catheters
Authors: Freebairn R. C. , Buckley T. A. , Twyford C. J. , Oh T. E.
Published: January 2019

We investigated the accuracy of recycled gastric tonometer catheters, using a prospective laboratory model, within the Intensive Care Unit of a University teaching hospital.

Ten used tonometer catheters and three new catheters were exposed to known constant PCO2 levels between 23–65 torr (3.06–8.66 kPa) in a gas mixing chamber, at a temperature of 35.5–38°C and a relative humidity >95%. The tonometer balloons were primed with normal saline, and after a 30-minute equilibration time, the saline was sampled for PCO2 measurements. Steady-state PCO2 (PCO2(ss)) and gastric mucosal pH (pHi) values were derived using a correction factor and the Henderson-Hasselbalch equation.

There was no difference in the mean or distribution of PCO2(ss) values between recycled and new catheters. The PCO2(ss) values of recycled catheters were within the 95% confidence limits of those of new catheters. Individual catheter values did not differ significantly from each other (ANOVA P=0.05). Using an arterial HCO3- value of 21 mmol/l, the calculated pHi values of used catheters varied <1.5% of the mean pHi of new catheters.

The tonometric performance of recycled gastric tonometer catheters was similar to that of new catheters when tested in vitro.
“Blind” Placement of Plastic Left Double-Lumen Tubes
Authors: Brodsky J. B. , Macario A. , Cannon W. B. , Mark J. B. D.
Published: January 2019

A prospective analysis of placement of left-sided plastic double-lumen tubes in 100 patients is presented. Intubation of the left bronchus was successfully accomplished using only auscultation and clinical signs (“blind” placement) in 91 patients. Double-lumen tubes were positioned in less than five minutes in 84 patients. The most common problem encountered (30%) was initial intubation of the right main bronchus. Seven of these patients required bronchoscopic assistance to guide the tube into the left bronchus. There were four minor intraoperative complications due to DLT malposition that were recognized and corrected by withdrawing the tube slightly back in the bronchus. The plastic double-lumen tubes functioned properly during the procedure in all 100 patients.