bluuebunny/crossref_metadata_2025 huggingface dataset:
Delivery of Anoxic Gas Mixtures in Anaesthesia: Case Report and Review of the Struggle towards Safer Standards of Care
Authors: Pauling M. , Ball C. M.
Published: January 2019

In 1983 a patient at The Alfred Hospital, Melbourne died during general anaesthesia for emergency surgery, in the weeks following maintenance to the operating theatre gas supply. In the ensuing investigation, it was revealed that he had been given 100% nitrous oxide throughout the anaesthetic due to the inadvertent crossing of the nitrous oxide and oxygen pipelines during the repair work. In this article we review the published literature on the delivery of hypoxic and anoxic gas mixtures, and the associated morbidity and mortality. We explore the developments that took place in the delivery of anaesthetic gases, and the unforeseen dangers associated with these advances. We consider the risks to patient safety when technological advances outpaced the implementation of essential safety standards. We investigate the events that pushed the development of safer standards of anaesthetic practice and patient monitoring, which have contributed to modern day theatre practice. Finally, we consider the risks that still exist in the hospital environment, and the need for on-going vigilance.
St John'S Hospital (Morton House), Launceston, Australia: A History of the Hospital and Dr William Russ Pugh'S First Operations under Ether
Authors: Haridas R. P. , Paull J. D.
Published: January 2019

On 7 June 1847, William Russ Pugh, MD, performed two operations at the St John's Hospital and Self-Supporting Dispensary, Launceston, Tasmania, while his patients were rendered insensible by the inhalation of sulphuric ether. These operations are the earliest documented surgical operations under ether in Australia. St John's Hospital officially opened on 1 September 1845. The hospital may have closed in late 1853 because of financial difficulties. The two-storey Georgian-style building which served as the hospital was completed c1831–1832. It has served as a residence, school, boarding school, hospital, medical consulting rooms and commercial offices. The building is now known as Morton House. We could not identify the date when the name Morton House was adopted, or explain the origin of the name. The earliest identified use of this name is in May 1873 in a newspaper advertisement for boarders. No person with the surname Morton is known to have been associated with the building as an owner or as a tenant. The name Morton House may honour William T.G. Morton, MD, the Boston dentist who performed the first public demonstration of surgical etherisation on 16 October 1846.
The Possible Role of the Carotid Bodies as Chemoreceptors in the Laryngeal Reflex
Authors: Rex M. A. E.
Published: January 2019

The glossopharyngeal nerve may carry afferent fibres which provide pathways for the laryngeal reflex. Evidence is presented which suggests that volatile anaesthetics may stimulate effects at the carotid bodies, which are innervated by the sinus nerves (branches of the glossopharyngeal nerve). Experiments were carried out on cats in which the effects of intravenous injections of solutions of ether and hydrogen cyanide were compared.
The pH and Titratable Acidity of Intravenous Infusion Solutions
Authors: Gaudry P. L. , Duffy C. , Bookallil M. J.
Published: January 2019

The acidic nature of infusion solutions may contribute to local thrombophlebitis or systemic acidosis. The pH of four commercially available solutions ranged from 4·55 to 6·40 and titratable acidities (to pH 7·4) ranged from 0·18 to 1·08 meq acid/litre. When equilibrated in vitro at PCO2 of 40 mm Hg the pH ranged from 4·5 to 6·0 and titratable acidity ranged from 20 to 26 meq acid/litre. Two solutions prepared from commercial solutions and containing 28 meq/litre sodium bicarbonate had a pH of 7·5 and a titratable acidity of 4–5 meq base/litre when equilibrated at a PCO2 of 40 mm Hg. Systemic acidosis due to some infusions may be prevented by the addition of sodium bicarbonate to the infusion solutions to produce a pH of 7·4 at PCO2 of 40 mm Hg.
Treatment of Pain of Carcinoma of the Tongue and Floor of the Mouth
Authors: Dwyer Brian
Published: January 2019

Fifty-two patients with uncontrolled pain due to carcinoma of the tongue and floor of the mouth were treated by the author as a member of a pain clinic.

The pain involved in part or in whole the sensory distribution of the trigeminal, facial, glossopharyngeal and vagus nerves and the superficial branches of the cervical plexus.

Treatment required attention to the general care of the patient through psychotherapy, reassurance, nutrition, etc.; the use of analgesics, antidepressants and sedatives; and sensory denervation of the affected areas.

Sensory denervation was achieved by chemical neurolysis with absolute alcohol in preference to direct surgical attack. The methods used follow the standard nerve block procedures with Bonica's technique for intrathecal alcohol preferred for the cervical plexus.

Eighty per cent of these patients received significant pain relief from this approach. Those who were unrelieved were managed by increasing doses of narcotic analgesics until their death.

The value of a pain clinic in the assessment and management of this form of intractable pain and the importance of the anaesthetist's role is emphasized.
Management of Acute Renal Failure
Authors: Hayes J. M.
Published: January 2019

Acute renal failure has oliguria and uraemia as its cardinal manifestations. The syndrome may be due to acute tubular necrosis, glomerulonephritis, urinary tract obstruction and occlusive vascular disease.

The renal damage due to acute tubular necrosis is of uncertain aetiology. Renal cortical ischaemia and depression of glomerular filtration rate are important in the pathogenesis. Activation of the renin-angiotensin system and glomerular coagulation may prove to be important in these changes.

The differentiation between reversible oliguria and established renal failure is generally accomplished on clinical grounds and the response to a therapeutic trial of mannitol. Measurement of urinary sodium concentration and osmolality are valuable adjuncts.

The keystone of management is the prevention of symptomatic uraemia. Infection and haemorrhage have now replaced pulmonary oedema and hyperkalaemia as the major causes of death. The mortality rate remains high in acute tubular necrosis and a significant mortality occurs in the diuretic phase.
The Prevention of Ketamine Dreams
Authors: Johnstone Michael
Published: January 2019

Surgical anaesthesia was induced with a 200–250 mg dose of ketamine given intravenously to each of 100 adult patients premedicated with nitrazepam 10 mg and droperidol 20 mg taken orally two hours before the injection of ketamine. Surgical operations were then performed with additional doses of ketamine, inhalational agents or pancuronium relaxant: 50 of the patients were maintained with inhalational agents and spontaneous breathing after the ketamine induction; 25 were maintained with intermittent supplementary doses of ketamine and spontaneously breathed air or oxygen; and 25 were fully curarized (pancuronium) for abdominal surgery and were mechanically ventilated with air or oxygen and anaesthesia was maintained with supplementary doses of ketamine 100 mg intravenously at 10-minute intervals. Careful postoperative interrogation of each patient revealed that all were anaesthetized throughout the period of surgery. The nitrazepam-droperidol mixture suppressed the dreams and mental agitation associated with the recovery from ketamine anaesthesia in adults. The mixture also suppressed the muscular catatonia sometimes precipitated by ketamine. Plethysmographic studies showed that ketamine causes dilatation of the alpha blood vessels, constriction of the beta blood vessels, and blocks the reflex alpha adrenergic vasoconstrictive reaction to surgical trauma.
Clinical Comparison of Tubocurarine and Pancuronium
Authors: Joseph Douglas , Bookallil Michael
Published: January 2019

In a blind trial, using matched pairs, intubation was found to be easier with pancuronium than with tubocurarine. There was a mean fall in blood pressure following the initial dose of tubocurarine but not after pancuronium. There was a greater rise in blood pressure following intubation with pancuronium than with tubocurarine. These differences could be recognized clinically.
A New Intensive Care Ward: Design and Medical Staffing
Authors: Davidson G. M.
Published: January 2019

The basis of planning, the final design, and the proposed medical staffing of a new 18-bed intensive care ward is described.
Oxygen Administration during Artificial Ventilation with Pressure Cycled Respirators
Authors: Morris M. Jocelyn , Cade David , Clarke Bernard
Published: January 2019

Inspired oxygen concentration has been measured when ventilating lung models and patients with Bird pressure cycled respirators. It has been found that with normal lungs the inspired oxygen concentration is predictable from the end-inspiratory pressure recorded on the respirator manometer. When lung mechanics are abnormal, the relationship between inspired oxygen concentration and end-inspiratory pressure is not sufficiently precise to allow accurate prediction of inspired concentration of oxygen.
The Management of Infants for Cardiac Surgery under Deep Hypothermia
Authors: Brown T. C. K. , Clarke C. P. , Shanahan E. A. , McKie B. D. , Wood H. M. , Thorp E. A.
Published: January 2019

Deep hypothermia is now employed for open heart surgery in infants. The method of surface cooling infants to 25° C and then by-pass cooling down to 15–20° C prior to exsanguination is described. This provides a still heart and ideal operating conditions. The infants are re-warmed on by-pass. Some of the physiological effects of hypothermia and the methods employed to counteract these are discussed. The aims are to reduce temperature gradients, improve cerebral oxygen supply, avoid arrhythmias and secure haemostasis.

The experience in 33 operations is outlined. Seventeen patients were under one year of age.
Ornipressin (Por. 8) for Haemostatic Infiltration in Neurosurgery
Authors: Torda T. A. , Gonski A. , Macdonald T. R. , McCulloch C. H.
Published: January 2019

A double blind controlled trial was carried out on 100 neurosurgical patients. Ornipressin 0·2 IU/ml was compared with adrenaline 1:250,000. Ornipressin proved to be as effective as the control agent, and had little systemic effect. It is concluded that absence of arrhythmigenicity makes ornipressin preferable to adrenaline.
Mechanical Factors Affecting the Evoked Pressures from a Simple Twitch Monitor
Authors: Shanks C. , Harrison G. A.
Published: January 2019

A syringe and aneroid manometer have been employed to quantitate neuromuscular blockade. The most important factors shown to vary its response were its air volume and the angulation of the syringe from the vertical. But even when these were held constant, the resultant pressures were not linearly related to the generative impulses. It is suggested that although this type of apparatus is not very accurate, the simple and inexpensive mechanism could benefit the practical anaesthetist monitoring nondepolarizing relaxants, providing its limitations are appreciated.
The Effectiveness and Duration of Preoperative Antacid Therapy
Authors: Newson A. J.
Published: January 2019

The administration of 10 ml of magnesium trisilicate mixture to premeditated patients, maintains the pH of gastric contents below pH 2·5 during subsequent general anaesthesia. This effect was sustained for over seven hours—the longest anaesthetic time studied. No antacid supplementation is required to offer protection from acid aspiration during emergence and initial recovery from general anaesthesia.
Thermographic Assessment of Peripheral Arterial Occlusion
Authors: Evans P. J. D. , Macey D. J. , Kerr J. H.
Published: January 2019

Infra-red thermography was used to confirm the observation that the temperature differences between corresponding areas of skin on opposing hands are normally minimal and to demonstrate that the skin temperature of the hand distal to an occluded radial or brachial artery was lower than that of the contra-lateral hand. Temperature differences between the two hands decreased with time and had disappeared by the time that recannulation of the occluded artery, gauged by the modified “Allen “test, had occurred. Thermography is a simple and non-invasive technique and provides a useful indicator of the incidence and progress of peripheral arterial occlusion such as that which may follow arterial cannulation.
Teaching Anaesthetics in the Operating Theatre
Authors: Paget Neil S. , Eaton Elena
Published: January 2019

During an anaesthetic procedure the anaesthetist's main concern is for the patient and his vigilance ensures that the patient is given the best care possible. When a trainee anaesthetist is administering an anaesthetic a tutor is often present to further improve the trainee's practical knowledge or technique. This report presents the results of an investigation of the typical patterns of trainee anaesthetist's behaviour when a tutor is either present or absent in order to establish whether the teaching which occurs in the operating theatre affects the pattern of activity and vigilance. Results indicate that the patterns of behaviour are unaffected by a tutor's presence, and that teaching anaesthetics in the operating theatre may be a legitimate activity which does not interfere with the trainee's prime function of patient care.
Life Support Systems in Intensive Care: A Review of History, Ethics, Cost, Benefit and Rational Use
Authors: Phillips G. D.
Published: January 2019

This paper outlines the development of life support systems, i.e. artificial support systems for failing essential organs such as heart, lungs, kidneys and gastrointestinal tract. The current status of organ support is discussed, particularly in relation to intensive care units. Ethical problems posed by the availability of these systems are presented, cost and cost/benefit ratios are discussed, and proposals are made for the rational use of life support systems in the intensive care situation.
“Dextrostix” Revisited
Authors: McCleave D. J. , Fisher M. McD.
Published: January 2019

A clinical trial compared blood glucose measurements obtained with reagent strips and the Eyetone Meter with those obtained on an AutoAnalyser. The blood glucose readings obtained with the Eyetone Meter were sufficiently accurate for clinical use in Intensive Care Medicine and Anaesthesia.
A New Laryngoscope
Authors: Grant G. C.
Published: January 2019

A new laryngoscope incorporates a mechanism operated from the handle which facilitates endotracheal intubation in situations where an introducing stylet would normally be required.
A Laryngoscope for Obstetrical Use an Obstetrical Laryngoscope
Authors: Kessell John
Published: January 2019

Rapid tracheal intubation, using the standard Macintosh laryngoscope, can be hindered in obstetrical patients by the handle of the laryngoscope hitting the patient's engorged breasts and the hand of the assistant applying cricoid pressure. To overcome these difficulties a variation of the laryngoscope is described. The right angle of the blade to the handle is opened by a further 20°.
The Effect of Positive End Expiratory Pressure on Rebreathing and Gas Dilution in the Ayre's T-Piece System—A Laboratory Study
Authors: Dobbinson T. L. , Fawcett E. R. , Bolton D. P. G.
Published: January 2019

The effect of positive end expiratory pressure on the function of the Ayre's T-Piece System was studied using a simple lung model.

Positive end expiratory pressure did not affect end tidal CO 2 during “controlled breathing” but caused an increase during “spontaneous breathing” when fresh gas flow was less than 3 times the minute volume. Gas dilution did not occur under any of the test conditions.
Studies of d-Tubocurarine Pharmacokinetics in Humans and Dogs
Authors: Ramzan I. M. , Shanks C. A. , Triggs E. J.
Published: January 2019

The pharmacokinetics of d-tubocurarine was studied in man during single and multiple administrations of d-tubocurarine, and in dogs during single administrations. The simplest model consistent with our data was a two-compartment open model. The mean half-lives for the two phases in the human studies were 8.9 and 123.8 minutes. For the greyhounds these mean values were 2.8 and 77.4 minutes. The animals did not demonstrate a difference between the arterial and mixed venous concentrations of d-tubocurarine.
Anaphylactic Reactions to Gallamine Triethiodide
Authors: Fisher M. McD.
Published: January 2019

Three cases of severe anaphylaxis to gallamine triethiodide are described. All reported cases of anaphylaxis to gallamine have occurred in women, and all the confirmed cases in Australasia. There is evidence that women may be exposed to some substance which leaves them sensitive to gallamine triethiodide.
An Oxygen Failure Warning and Patient Protection System. The Howison Unit
Authors: Holmes C. McK.
Published: January 2019

A device is described which sounds an alarm to warn of oxygen supply failure. A the same time the nitrous oxide flow is cut off, and a reservoir in the device provides a continuing oxygen flow to the patient for about a minute. This results in increased inspired oxygen levels temporarily, reducing the risk to the patient while the oxygen failure is being corrected.
Neurolytic Lumbar Sympathetic Blockade: Duration of Denervation and Relief of Rest Pain
Authors: Cousins M. J. , Reeve T. S. , Glynn C. J. , Walsh J. A. , Cherry D. A.
Published: January 2019

In an objective evaluation, 386 patients with rest pain due to occlusive vascular disease were studied before and after neurolytic lumbar sympathectomy by either 100% alcohol (n = 35), 6% phenol in water (n = 151) or 10% phenol in Conray 420 contrast medium (n = 200). A trained independent observer made assessments of:—

(a) Completeness and duration of sympathetic ablation;

(b) Degree and duration of pain relief;

(c) Changes in skin temperature and skin plethysmography;

(d) Completeness of coverage of antero-lateral aspects of L2, L3, and L4, by contrast medium (in patients receiving 10% phenol).

(e) Side effects, including L1 neuralgia and postural hypotension.

Mean duration of sweat test modification (6.0 ± 1.0 months) and pain relief (5.9 ± 0.6 months) were similar; onset of pain relief also coincided with onset of sympathetic blockade and increase in skin blood flow. This strongly pointed to sympathetic denervation as the basis for the relief of rest pain rather than a placebo response. Complete pain relief was achieved in 49% of patients, 31% had partial relief and 20% none. In the absence of pre-existing gangrenous changes a higher percentage of patients had complete or partial relief (84%) compared to those with gangrenous changes (56%). Significant postural hypotension was not observed. Frequency of L, neuralgia differed markedly for the three agents: 100% alcohol > 6% phenol in water > 10% phenol in Conray.

It is concluded that neurolytic lumbar sympathectomy is an effective method of relief of rest pain with the advantage over surgical sympathectomy of performance without general anaesthesia on an outpatient basis. It is estimated that, in a series of the size reported in this paper, the potential economic benefit could be a saving of the order of $360,000. The technique deserves further controlled evaluation in comparison to surgical sympathectomy.
Intravenous Erythromycin in Acute Chest Infections in Critically Ill Patients
Authors: Cade J. F. , Pain M. C. F.
Published: January 2019

Superinfections with resistant micro-organisms have recently become an increasing problem in hospital patients and are thought to be contributed to by inappropriate use of newer, broad-spectrum antibiotics. Erythromycin exhibits a more limited spectrum of antibacterial activity and was therefore re-evaluated in the treatment of acute chest infections in critically ill patients. Twenty-one patients were given erythromycin in a dose of 1.8 g per day by continuous intravenous infusion for up to five days. A satisfactory clinical response occurred in ten patients, in all of whom erythromycin-sensitive micro-organisms were isolated from sputum. An unsatisfactory response occurred in six patients, all associated with micro-organisms insensitive to erythromycin and requiring alternative antibiotic treatment. No undesirable side-effects were noted. It is concluded that erythromycin is a safe and useful agent in the routine treatment of acute chest infections in critically ill patients.
The Short Term Distribution of Thiopentone in the Dog
Authors: Crankshaw D. P. , Rosler A. , Ware Merran
Published: January 2019

Rapid sampling of arterial blood following intravenous infusion of thiopentone at various speeds has demonstrated that the peak concentrations for doses given over five seconds are at least twice those for doses given over fifteen seconds. The area under the curves and the dispersed arterial concentrations show no significant difference between injection speeds.
Cardiac Tamponade Caused by Caval Catheter — A Radiological Demonstration of an Unusual Complication
Authors: James O. F. , Tredrea C. R.
Published: January 2019

An adult male developed shock some hours after the start of intravenous alimentation. The caval catheter, which had been inserted through the right subclavian vein, was later radiographically demonstrated to be in the pericardial sac. We reviewed the literature on this and other complications of caval catheters. From this information and our own experience we offer some suggestions for prevention and management of some of the complications of caval catheters.
Medical Staff Needed in a Hospital to Service Anaesthesia and Intensive Care
Authors: Smallwood Robin W. , Sando Maurice J. W. , Holland Ross B.
Published: January 2019

A method is presented for determining the number of medical staff needed in a hospital to provide a high standard service in anaesthesia and intensive care. The method depends on dividing duties into those which are easily recognisable as service duties, and other duties which are not but which affect the quality of the service. The portion of the working week available for service duties is determined for each member of staff and, after allowing for leave entitlements, the annual contribution of half days to these duties is calculated. The annual service commitment of the department is worked out in half day units and a relatively simple calculation will then show how many staff are needed. The method automatically provides for all aspects of the job, not just the service element.
Intravenous Chlormethiazole — Haemolysis with Concentrated Solutions
Authors: Runciman W. B. , Ilsley A. H. , Ryall R. G. , Parkin K. S. , Heinrich R.
Published: January 2019

Since the current clinical concentration of chlormethiazole solutions (0.8%) may require the infusion of large volumes of fluid, it was decided to examine the effects on haemolysis of infusing higher concentrations of chlormethiazole into a central vein. Approximately one gram of chlormethiazole was infused into the inferior vena cavae of six anaesthetised greyhounds over each half hour using, successively, 0.8%, 1.2%, 2%, 5%, 10%, and 20% solutions of chlormethiazole. Free plasma haemoglobin levels were measured at five minute intervals, and blood chlormethiazole levels at 15 minute intervals. A rapidly progressive haemolysis occurred when the 5 or 10% solutions were infused. In a further four greyhounds, one gram of chlormethiazole was infused over each half hour using a 0.8% solution, whilst progressively hyperosmolar dextrose solutions were infused at the same rates in succeeding half hours as the concentrated chlormethiazole solutions had been infused in the first six dogs. No haemolysis occurred in these control animals. Chlormethiazole blood levels were similar in each group. Loss of chlormethiazole into the infusion tubing was examined and found to be 20% for the 0.8% solution, and 10% for the 1.2% solution, but was insignificant with the other subsequently infused concentrations of chlormethiazole. It is concluded that rapid progressive haemolysis occurs in association with the infusion of chlormethiazole solutions when concentrations of greater than 5 or 10% are infused into the inferior vena cavae of anaesthetised greyhounds.
Body Temperature Changes during Transurethral Prostatectomy
Authors: Rawstron R. E. , Walton J. K.
Published: January 2019

A prospective trial was made to investigate the effects of cold irrigating solutions on body temperatures during transurethral resection of the prostate. In a control group of 45 cases, when the irrigating fluids had a mean temperature of 21.9°C, there was a significant fall in body temperature from 36 ± 0.6°C to 34.9 ± 0.7°C. In test group A of 48 cases, when the irrigating fluids had a mean temperature of 4.96°C, there was a significant fall in body temperature from 36.1 ± 0.6°C to 34.8 ± 0.9°C.

In test group B (five cases) when the irrigating fluids had a mean temperature of 10.2 °C there was a significant fall in body temperature from 36.0 ± 0.4 to 34.6 ± 0.8.

Comparative analyses between the control group and test group A did not show significant differences in the degrees of cooling in the two groups.
An Academic Department of Anaesthesia in a New Canadian Medical School
Authors: Rigg John R. A.
Published: January 2019

The development of an academic department of anaesthesia over its first ten years at McMaster Medical School in Hamilton, Ontario, Canada, is described. The organisation and goals of the department are described within the context of the regional organisation of health care delivery and of the functions of the faculty of health sciences.

The activities of department members in various educational programmes, particularly the undergraduate and postgraduate programmes, are described in detail and the roles of the department in research and clinical anaesthesia and related clinical activities are also described. The role of an academic department of anaesthesia within a community of specialist anaesthetists is discussed.
The Anaesthetic Management of a Patient with a Broncho-Pleural Fistula and Intestinal Obstruction
Authors: Zideman D. A. , Scott Andrew
Published: January 2019

A patient with a broncho-pleural fistula presented for emergency laparotomy for intestinal obstruction. Anaesthesia was managed with neuroleptanalgesia, and with endobronchial intubation before induction of anaesthesia.
A Technique for Subcutaneous Tunnelling of a Subclavian Catheter
Authors: Older Paul O. , Levitt M.
Published: January 2019

A method is described whereby a silicone elastomer catheter may be introduced into the subclavian vein and then tunnelled retrograde to a remote site. The advantages of this technique are discussed.
Parenteral Administration of Trace Elements to Critically Ill Patients
Authors: Phillips G. D. , Garnys V. P.
Published: January 2019

Studies of zinc, copper, manganese, chromium, selenium and molybdenum balance were carried out in eight patients in an intensive care unit. In six of these, nickel balance was also measured. The amount of each element in fluid administered to the patients, and the amount lost in urine and gastrointestinal fluid on each of seven days, was measured by atomic absorption spectrometry and cumulative balances calculated.

Satisfactory balances of zinc, copper and manganese were obtained when the amounts administered approximated those currently recommended. Chromium balances were variable, while those of molybdenum, selenium and nickel were negative in most patients. Interpretation of balance studies of this type in critically ill patients is made difficult by abnormal renal and gastrointestinal function.
The Diagnosis of Acute Anaphylactoid Reactions to Anaesthetic Drugs
Authors: Fisher M. McD.
Published: January 2019

Patients with a presumptive diagnosis of an acute anaphylactoid reaction to anaesthesia were investigated to determine the cause of the reaction and the drug responsible by intradermal testing, patch and prick testing, sequential complement measurement, passive transfer testing and challenge. The most valuable information was provided by intradermal testing and a diagnosis could be made in 150 of 165 patients.

When anaphylactoid reactions to anaesthetic drugs occur, intradermal testing one month after the reaction and sequential complement measurements in the immediate post reaction period will enable the diagnosis to be established in the majority of cases. Intradermal testing is of no value for trivial reactions or reactions to colloid solutions or contrast media.
Intravenous Nitroglycerin during Surgery for Coronary Artery Disease
Authors: Kaye S. E. , Dimai W. , Gattiker R.
Published: January 2019

Intravenous infusions of nitroglycerin decreased systemic systolic, pulmonary systolic and wedge pressures in β-blocked patients anaesthetised for coronary artery surgery with high dose of fentanyl without changing heart rate, diastolic pressure, or cardiac index, thus leading to an improvement in endocardial viability ratio.

The use of a nitroglycerin bolus to abort an acute myocardial ischaemic episode is described.
Epidemiology and Prevention of Pseudomonas Aeruginosa Chest Infection in an Intensive Care Unit
Authors: Seal D. V. , Strangeways Janet M.
Published: January 2019

An epidemiological investigation of Pseudomonas aeruginosa in an Intensive Care Neurosurgical Unit has shown that there were epidemic, endemic and endogenous types present simultaneously.

These pseudomonads were cultured from purulent sputa postoperatively and sometimes caused systemic disease.

The epidemic type was traced to a ventilator and a nebulizer whilst the endemic and endogenous types were not found in environmental sites. Effective decontamination of equipment and the use of bacterial filters where possible are essential in preventing the spread of infection. Staff hygiene remains important, particularly hand washing with antiseptic soap preparations.
Inorganic Mercurial Poisoning
Authors: Datyner Michael E. , Cox Peter A.
Published: January 2019

The clinical course of a patient who ingested inorganic mercurial compounds is described. The toxicity of these compounds is discussed and approaches to management outlined. As the long term prognosis in such cases is uncertain, intensive resuscitation and supportive therapy would appear to be justified.
Total Spinal Block Complicating Epidural Analgesia in Labour
Authors: Skowronski George A. , Rigg John R. A.
Published: January 2019

A 26-year-old woman sustained accidental total spinal block following induction of epidural analgesia for labour, despite conventional precautions for prevention of this complication. Unusual features included slow onset of block, only slight hypotension, the need for a muscle relaxant drug to assist with intubation, and only a brief period of unconsciousness. Possible mechanisms include massive subarachnoid block, subdural block, and massive epidural block. This case demonstrates that conventional precautions do not preclude accidental total spinal anaesthesia, and that drugs, equipment, and an anaesthetist must be readily available in all areas where epidural analgesia is in progress.
Late Perforation of Superior Vena Cava and Effusion Caused by Central Venous Catheter
Authors: Criado A. , Mena A. , Figueredo R. , Reig E. , Avello F.
Published: January 2019

A patient developed right-side pleural effusion secondary to perforation of the superior vena cava by a catheter which had been inserted seven days previously through the left internal jugular vein.
A Three-Year Survey of an Obstetric Epidural Service with Top-Up Doses Administered by Midwives
Authors: Brownridge P.
Published: January 2019

A three-year survey following the introduction of an epidural service to a maternity unit is presented. 1,438 epidural blocks were attempted (a rate of 30%). Provision of pain relief was the principal indication. There were no serious complications or sequelae although minor complications or difficulties of insertion were noted in 21%. The procedure was abandoned in 1.5% and accidental dural tap occurred in 1.7%. Satisfactory pain relief was achieved in 90% during the first stage of labour and 71 % during delivery. Of those who delivered, 47% retained an urge to bear down and spontaneous delivery occurred in 43%. 89% of patients interviewed were fully satisfied with, or considerably helped by, the epidural block. Incremental epidural doses were managed by midwives and it is argued that the midwife is ideally suited to this role providing she is trained and experienced and can call for immediate anaesthetic assistance.
Treatment of Central Venous Silastic Catheter Infections Using Hydrochloric Acid
Authors: Worthley L. I. G.
Published: January 2019

Patients receiving long-term home parenteral nutrition through a subcutaneously tunnelled central venous silastic catheter underwent a trial of 1.5 ml of 2M hydrochloric acid instilled into the catheter each time an episode of catheter sepsis was diagnosed. Four patients had eleven episodes of central venous catheter infection, with the hydrochloric acid clearing the infection on seven occasions, and unblocking the catheter once.

The mainstay of therapy for catheter sepsis is removal of the catheter. However, in patients with subcutaneously tunnelled central venous silastic catheters, if reinserting the catheter is anticipated to be a major problem then a small dose of hydrochloric acid in an attempt to clear the infection may be worth a trial.
Pulmonary Extraction of Catecholamines in Critically Ill Patients
Authors: Russell W. John , Frewin Derek B. , Jonsson Julie R.
Published: January 2019

Plasma catecholamine concentrations in blood obtained simultaneously from the pulmonary and radial arteries of ten critically ill patients have been measured. The mean mixed venous concentrations of noradrenaline, adrenaline and dopamine were extremely high, noradrenaline 11.3 pmol/ml (SD 11.6), adrenaline 2.7 pmol/ml (SD 3.0) and dopamine 7.1 pmol/ml (SD 12.3). An appreciable drop in the concentrations occurred as the blood passed from the pulmonary artery to the radial artery (mean fall 24.1, 29.7 and 45.8% respectively). Four patients receiving a therapeutic dopamine infusion were also studied and demonstrated similar trends in catecholamine concentrations. The results suggest a substantial pulmonary clearance mechanism for all three catecholamines.
Cardiovascular Risk Factors in Patients for Vascular Surgery
Authors: Domaingue C. M. , Davies M. J. , Cronin K. D.
Published: January 2019

Various attempts have made been made to quantify the cardiovascular risk factors associated with anaesthesia and surgery. Two such schemes are the “Multifactorial Index of Cardiac Risk” developed by Goldman et al., and the one devised by Cooperman et al. The validity of these two schemes in relation to anaesthesia for vascular surgery was investigated by carrying out a prospective study of 100 patients. Cooperman's scheme was found to be much more accurate than Goldman's scheme in assessing patient risk. The study confirms the impression that the vascular patient falls into a higher risk group than most other surgical patients with regard to cardiovascular complications.
The Lack and Bain Systems in Spontaneous Respiration
Authors: Nott M. R. , Walters F. J. M. , Norman J.
Published: January 2019

In conscious subjects breathing spontaneously the performance of the Lack semi-closed system resembled the Magill attachment in that rebreathing was only detected at fresh gas flows of less than resting minute volume. With the Bain semi-closed system rebreathing was detectable at fresh gas flows of the order of 2.5 times the minute volume. The two co-axial circuits behaved similarly for anaesthetised patients. In adults breathing spontaneously the Lack system is efficient and more economical than the Bain.
Midazolam, a Water-soluble Benzodiazepine, for Gastroscopy
Authors: Brophy Tess , Dundee J. W. , Heazelwood V. , Kawar P. , Varghese A. , Ward M.
Published: January 2019

Midazolam, a water-soluble benzodiazepine, was given intravenously in doses of 0.07 mg/kg as sedation prior to oesophago-gastro-duodenoscopy in 40 patients. This was very effective as a sedative in elderly patients but less so in the young, with a large individual variation in response. Pain on injection and venous thrombosis which are common with diazepam were not seen with midazolam.
The Permit to Work System
Authors: Seed R. F.
Published: January 2019

Accidents due to medical gas systems being incorrectly installed or assembled have drawn attention to the need for rigid control over maintenance of contracts and standards, communication and responsibility allocation whenever work on such systems is undertaken. The format of a Permit to Work System introduced into a large general hospital is described, based on local needs, and its application has highlighted the value of such a system.
Neurolytic Lumbar Sympathetic Blockade: A Modified Technique
Authors: Klopfer Gary T.
Published: January 2019

A modification of the traditional method of lumbar sympathetic blockade is described. A semiprone patient position, combined with vertical X-ray screening, are employed to facilitate determination of the level and angle of needle insertion.
A Double Blind Comparison of Alfentanil and Fentanyl
Authors: Liberman H. , Pybus D. A. , Torda T. A.
Published: January 2019

Alfentanil and fentanyl were compared as supplements to thiopentone, nitrous oxide, relaxant anaesthesia in a randomised, double blind trial carried out on 55 adult patients undergoing elective surgery. The fentanyl-treated patients resumed spontaneous ventilation more rapidly at the end of anaesthesia (3 minutes) than the alfentanil-treated group (5.1 minutes, p < 0.02). In other respects the drugs appeared indistinguishable. A computer model is used to explain why, despite the shorter elimination half-life, the alfentanil-treated patients did not awaken more rapidly than those in the fentanyl group.
Acute Epiglottitis in Children
Authors: Baines David B. , Wark Harry , Overton John H.
Published: January 2019

The records of one hundred and sixty-one children with acute epiglottitis admitted to the Royal Alexandra Hospital for Children between January 1975 and June 1984 were reviewed. Forty-five complications occurred in thirty-four patients, including five deaths. The preferred method of airway management is direct laryngoscopy and nasotracheal intubation under general anaesthesia in the presence of skilled assistance. There should be no attempt to lie the child down prior to this, nor should awake laryngoscopy be attempted, as this may precipitate a respiratory arrest. Chloramphenicol (with or without ampicillin) should be commenced after blood cultures are obtained, as 20% of the sensitivities available demonstrated resistance to ampicillin.
Intravascular Monitoring via the Axillary Artery
Authors: Brown Morris , Gordon Lawrence H. , Brown O. William , Brown Eli M.
Published: January 2019

Axillary artery cannulation was performed in 31 patients in whom the radial arteries were unavailable or unsuitable for cannulation. The artery was first cannulated with an 18-gauge needle, after which a Seldinger guide wire (0.032-inch diameter) was passed, which was used to introduce a 6-inch, 18-gauge Teflon ® catheter. The mean duration of cannulation was 3.2 days (range 19 hours to 8 days). All patients were assessed for complications of the procedure up to 72 hours after decannulation. No serious complications were encountered. It is concluded that the axillary artery is a safe alternative in the absence of an available radial artery when arterial cannulation is indicated.
Cardiac Pacing in Intensive Care
Authors: Donovan Karl D.
Published: January 2019

Cardiac pacing techniques and equipment have developed dramatically in recent years. Bradycardias and tachycardias may be effectively treated by pacing.

Bradyarrhythmias: It is generally accepted that pacing is indicated for a sustained symptomatic bradycardia. Prophylactic pacing for‘high-risk’ bundle branch block in acute myocardial infarction is more controversial. A new era in cardiology has been introduced with the advent of‘physiological pacing’, i.e. pacing of the heart with the maintenance of atrioventricular synchrony and varying the heart rate according to the body's metabolic leads. Modern pacing systems, which allow the atria and ventricles to contract in sequence, improve cardiac haemodynamics, result in subjective improvement and increase exercise tolerance. There are, however, pacemaker-associated and pacemaker-mediated tachyarrhythmias. Further advances in technology should overcome these problems.

Tachyarrhythmias: Intracardiac electrocardiograms are often useful in the diagnosis of tachyarrhythmias, especially wide complex tachycardias. Rapid pacing of the atria in certain supraventricular tachycardias or of the ventricle in ventricular tachycardia is an alternative to cardioversion in many instances. This form of treatment is usually utilised in conjunction with drug therapy.
Indications for and Complications of Temporary Transvenous Cardiac Pacing
Authors: Donovan Karl D. , Lee K. Y.
Published: January 2019

A prospective survey was conducted of the indications for and complications of 153 temporary transvenous cardiac pacing lead insertions in 148 patients. Pacing for bradyarrhythmias or potential bradyarrhythmias (Group I) accounted for 105 insertions, wide complex tachycardia (Group II) 17, and narrow complex tachycardia (Group III) 31 pacing electrode insertions respectively. The infraclavicular subclavian vein approach was used in 73%. The median insertion time was 20 minutes. Group I: 77% were undertaken because of severe symptoms. On 64 occasions (61 %) the patient had complete heart block or ventricular asystole. Group II: The lead was inserted to treat and often assist in the diagnosis of the wide complex tachycardia. Ventricular‘burst’ pacing reverted ventricular tachycardia in 13 (76%). Group III: Rapid atrial‘burst’ pacing was used to treat supraventricular tachyarrhythmias (paroxysmal supraventricular tachycardia and atrial flutter) resistant to medical therapy. Pacing was successful in reverting 28 (90%). A complication occurred in 27 (18%) of 153 lead insertions, 11 (7%) were serious. No complication resulted in the death of a patient. Temporary transvenous pacing is safe and effective for the treatment of bradyarrhythmias and certain tachyarrhythmias.
Acute Enteric Sepsis: Bacteriology and Antibiotic Cover
Authors: Steele T. W.
Published: January 2019

Most cases of enteric sepsis are caused by both aerobic and anaerobic organisms which form the normal flora of the mouth and lower gastrointestinal tract. This flora is extremely variable and subject to change due to disease and antimicrobial treatment. Bacteriological investigation of patients with severe enteric sepsis is important and should be undertaken before antibiotic treatment is commenced. The choice of antibiotics depends on the nature of the infection and its location.

Initially they should be given in maximum dosage. If polymicrobial infection is suspected both aerobes and anaerobes should be covered to prevent bacteraemic shock and abscess formation. If abscesses have formed or the patient fails to respond to appropriate antibiotics, surgical exploration and drainage remain the treatment of choice. Antibiotics often fail to eradicate organisms from established abscesses and are responsible for some serious complications.
Abdominal Trauma: Pre-operative Assessment and Postoperative Problems in Intensive Care
Authors: Webster V. J.
Published: January 2019

Although penetrating abdominal trauma is on the increase in Australia, blunt trauma continues to account for the majority of cases and usually presents a more challenging problem than the former. Diagnosis has been greatly facilitated by the widespread use of peritoneal lavage and computerised tomography. Conservative management of solid organ ruptures, especially of the spleen, is being increasingly utilised in selected cases. If haemorrhage continues following initial resuscitation, urgent laparotomy is required. Heroic attempts at achieving normovolaemia in the presence of major haemorrhage must not be allowed to delay laparotomy. Postoperative problems such as intra-abdominal sepsis or visceral infarction usually have few if any localising features; more typically multiple organ failure insidiously develops. When no clear extra-abdominal cause exists, laparotomy must not be delayed.
Acute Abdominal Disorders in the Paralysed Patient
Authors: Worthley L. I. G.
Published: January 2019

In the paralysed and sedated patient, acute abdominal diseases are difficult to diagnose. Clinical signs such as tenderness, rebound, guarding and rigidity are often misleading or absent and in the fully monitored, critically ill patient, the abdominal X-ray, ultrasound and CT scan may be associated with a high incidence of artifact abnormality.

The acute abdominal disorders commonly found in the critically ill patient are listed, the diagnostic approach using standard clinical and investigational methods is considered, and the problems commonly encountered by the clinician are highlighted.
Fulminant Hepatic Failure
Authors: Hetzel David J.
Published: January 2019

Fulminant hepatic failure is an uncommon but dramatic illness with a high mortality. Viral hepatitis or drug toxicity is the usual cause. In the severe forms of the illness the patients, often young and previously healthy, rapidly become profoundly unwell due to extensive hepatic necrosis. Coma is accompanied by a disastrous disturbance of all the synthetic, metabolic and excretory functions of the liver. Management is largely supportive and multisystem complications may demand all the resources of the intensive care unit to allow survival. Systems for temporary hepatic support have aroused interest, based on the assumption that the hepatic lesion is potentially reversible. A number of heroic techniques have been tried and abandoned. Encouraging reports of charcoal column haemoperfusion have yet to be confirmed by controlled clinical trial.
Enteral Feeding — A Practical Approach
Authors: Phillips P. J. , Fazio V. A.
Published: January 2019

Many patients in large hospitals require nutritional support to avoid the increased morbidity and mortality associated with malnutrition. Parenteral nutrition has been used for more than fifteen years but is expensive and can be hazardous. Most hospital patients requiring nutritional support can be fed through the gastrointestinal tract. Enteral nutrition can be delivered safely and cheaply orally or by tubes temporarily implanted. We outline a simple step approach from oral nutrition using a palatable, inexpensive, chemically defined, complete diet to jejunal nutrition using an implanted feeding tube and an‘elemental’ dietary supplement: oral first, enteral next, parenteral when necessary.
Total Parenteral Nutrition in Acute Illness
Authors: Phillips G. D.
Published: January 2019

Successful total parenteral nutrition in acute illness requires an appreciation of the pathophysiology of the illness and an understanding of the nutritional state of the patient, as well as a knowledge of the principles of total parenteral nutrition. Management of the acutely ill patient's general condition is essential prior to the introduction of nutritional support.

A basic regimen which includes administration of 1–2g/kg/day of protein, and 8,400 kJ (2,000 kcal)/day of energy, part glucose and part lipid, together with all minerals, vitamins and zinc, in an appropriate amount of water, should be provided. Modifications to this regimen may be indicated to accommodate cardiac, respiratory, liver or renal failure.

The questions of the optimum mix of carbohydrate and lipid, the ideal amount of protein and the correct mix of amino acids for a particular period in an individual patient's illness, are still debated. The fact that recent research supports many of the postulates of the Scandinavian pioneers of total parenteral nutrition suggests we may be returning to a correct approach.