bluuebunny/crossref_metadata_2025 huggingface dataset:
The depth of anaesthesia associated with the administration of isoflurane 2.5% during cardiopulmonary bypass
Authors: Alston R Peter , Connelly Michael , MacKenzie Christopher , Just George , Homer Natalie
Published: January 2019

Background:

Administering isoflurane 2.5% into the oxygenator during cardiopulmonary bypass results in no patient movement. However, doing so may result in an excessive depth of anaesthesia particularly, when hypothermia is induced. Bispectral index and arterial blood and oxygenator exhaust concentrations of volatile anaesthetics should be related to depth of anaesthesia. The primary aim of this study was to measure the depth of anaesthesia using bispectral index, resulting from administering isoflurane 2.5% into the oxygenator during cardiopulmonary bypass, and secondary aims were to examine the relationships between blood and oxygenator exhaust isoflurane concentrations and bispectral index.

Methods:

Arterial and mixed-venous blood samples were aspirated at three time points during cardiopulmonary bypass and measured for isoflurane concentration using mass spectrometry. Simultaneously, oxygenator exhaust isoflurane concentration, nasopharyngeal temperature and bispectral index were recorded.

Results:

When averaged across the three time points, all patients had a bispectral index score below 40 (binomial test, p < 0.001). There were no significant correlations between bispectral index score and arterial or mixed-venous blood isoflurane concentrations (r = –0.082, p = 0.715; r = –0.036, p = 0.874) and oxygenator exhaust gas concentration of isoflurane (r = –0.369, p = 0.091).

Conclusion:

When 2.5% isoflurane was administered into the sweep gas supply to the oxygenator during cardiopulmonary bypass, all patients experienced a bispectral index score less than 40 and no significant relationship was found between either arterial or mixed-venous blood or oxygenator exhaust concentrations of isoflurane and bispectral index.
Generic Polymerase Chain Reaction Followed by DNA Sequencing as a Means of Diagnosing Bacteraemia
Authors: Sleigh J. W. , Cursons R. T.
Published: January 2019

There is increasing use of polymerase chain reaction techniques to diagnose infection. We report the use of polymerase chain reaction using a generic section of the bacterial 16S rDNA gene—followed by nucleotide sequencing—to determine the species of the infecting bacteria. In the first case, the clinical and microbiological diagnosis of meningococcal septicaemia was in agreement with the results from polymerase chain reaction technique. In the second case, a Yersinia enterocolitica bacteremia was detected by the polymerase chain reaction technique, but missed with conventional blood culture techniques.
The Accuracy and Reliability of an Infusion Pump (STC-3121; Terumo Inst., Japan) during Hyperbaric Oxygenation
Authors: Dohgomori H. , Arikawa K. , Kubo H.
Published: January 2019

We evaluated the accuracy of delivery of one type of infusion pump at three nominal flow rates under two environmental pressures (measured in atmospheres absolute, ATA), one of which is used for hyperbaric oxygenation. Overall, we observed significant differences between the two different pressures (1 ATA and 2 ATA). Changes in the rate of delivery of between about −4% and +2% were observed over the time course of hyperbaric oxygenation, and the inter-group difference was significant in the phases in which pressure was changing. The effect produced by 2 ATA was statistically significant but small, and its influence is likely to be negligible during practical hyperbaric oxygenation therapy. Thus, it would seem that this type of pump would deliver reliably at the nominal rate during hyperbaric oxygenation at these levels.
Dental Trauma Associated with Anaesthesia
Authors: Owen H. , Waddell-Smith I.
Published: January 2019

Damage to teeth is the most common complaint against anaesthetists. A dental history and oral examination are important before anaesthesia. Pre-existing dental pathology or the presence of prostheses makes damage more likely but sound teeth may be affected. The maxillary central incisors are most at risk. Certain diseases and drugs should alert anaesthetists to increased likelihood of dental pathology. The flange of the Macintosh blade appears responsible for much damage and alternative equipment or techniques of endotracheal intubation should be considered, particularly when risk factors are present. Manoeuvres to protect teeth must not impact adversely on airway management. Custom mouthguards can be useful. A management plan can help control losses if damage does occur. Patients should be warned about the possibility of dental trauma.
A Case for Steroids in Acute Lung Injury Associated with the Retinoic Acid Syndrome
Authors: Cupitt J. M.
Published: January 2019

A 62-year-old woman with acute promyelocytic leukaemia was treated with all-trans retinoic acid. On day 2 she suffered with dyspnoea and general fatigue. Marked hypoxia suggested the occurrence of retinoic acid syndrome. She underwent endotracheal intubation and mechanical ventilation with the administration of dexamethasone. Her symptoms promptly abated. She was subsequently treated with conventional chemotherapy and achieved complete remission.
The Effect of Adjunctive Fresh Frozen Plasma Administration on Coagulation Parameters and Survival in a Canine Model of Antivenom-treated Brown Snake Envenoming
Authors: Jelinek G. A. , Smith A. , Lynch D. , Celenza A. , Irving I. , Michalopoulos N. , Erber W. , Joske D. J. L.
Published: January 2019

This study aimed to assess the effects of dugite envenoming on blood coagulation and platelet count in a canine model, and the efficacy of fresh frozen plasma (FFP) in reversing the clotting disorder after both adequate and inadequate venom neutralization. Following initial dosing and administration studies, an intravenous venom dose of 1μg/kg was administered to eleven dogs. This was followed 30 minutes later by antivenom in either adequate or inadequate doses. A further 30 minutes later, the animals were given either two units of their own FFP or saline. Fibrinogen, aPTT and platelet levels were monitored for eight hours.

Of the six study dogs given antivenom plus FFP, two died at around 60 to 90 minutes post envenoming, at the end of the FFP infusions, and all but one of the survivors had persistent afibrinogenaemia. Of the five study dogs given antivenom and no FFP, all but one had return of detectable fibrinogen at eight hours after envenoming. The platelet count fell in all animals with recovery independent of antivenom dose, administration of FFP, or regeneration of fibrinogen. Post mortem examinations of dogs that died during dosage and administration studies showed massive intracardiac clots.

We conclude that early death from Brown Snake envenoming may be due to massive intravascular clotting. FFP administration was associated with persistent afibrinogenaemia regardless of antivenom dose. In the absence of any evidence for its efficacy, this study suggests that the role of FFP after Brown Snake envenoming should be reconsidered.
Transfusion-Related Acute Lung Injury (TRALI)
Authors: Teague G. , Hughes A. , Gaylard D.
Published: January 2019

A 50-year-old male presented for a Whipple's procedure to excise a pancreatic lesion. Massive transfusion of packed cells and fresh frozen plasma was required. Towards the end of the procedure, the patient developed sudden onset of frank pulmonary oedema and hypotension. A presumptive diagnosis of transfusion related lung injury was made after prompt investigations excluded circulatory overload or cardiogenic shock as the cause. This case report describes an increasingly common and life-threatening sequela of blood product transfusion, the management of which is complicated by the current lack of specific diagnostic tests.
Brian Dwyer and the St. Vincent's Pain Clinic 1962 to 1989
Authors: Gibb D. B.
Published: January 2019

Brian Dwyer was the Director of the Department of Anaesthetics at St. Vincent's Hospital in Sydney from 1955 to 1985. He developed a major interest in the management of intractable pain and was most impressed by the multidisciplinary pain clinic which was commissioned at the University of Washington in Seattle by John Bonica in 1960. In August 1962, Dr Dwyer established the first pain clinic in Australia, based on the Seattle model. Initially the St. Vincent's Pain Clinic specialized in the management of pain of malignant origin but in the 1970s and 1980s the work expanded to include the treatment of pain arising from a variety of benign conditions. The great strengths of the Pain Clinic were its multidisciplinary approach to pain problems and the realisation of the importance of psychological factors in the persistence of pain. As a result of his work, Brian Dwyer received international recognition as a pioneer in the field of chronic pain management and the St. Vincent's Pain Clinic served as a model for the establishment of similar units, both in Australia and overseas. Brian Dwyer was the first chairman of the Clinic and remained in that position until his retirement in 1989.
Multislice Computed Tomography Coronary Angiography: Risk Stratification of Patients in the Perioperative Period
Authors: Weinberg L. , Spanger M. C. , Harley I. , Story D. A. , Hall A.
Published: January 2019

Multislice computed tomography coronary angiography is emerging as a reliable noninvasive method for the assessmentofcoronaryarterydisease, coronaryanatomyand cardiac function. Improvements in computed tomography technology hold the promise of replacing the standard invasive procedure of conventional coronary angiography in selected patient groups. The ability of a six-second scan to identify flow-limiting coronary artery stenoses as well as characterising coronary atheromatous plaque components provides valuable information that can assist in refining perioperative cardiovascular risk. Multislice computed tomography's high negative predictive value and high specificity for stenoses allows it to effectively rule out coronary artery disease in patients with cardiac risk factors who have non-diagnostic or equivocal noninvasive cardiac stress tests. Other uses include evaluating patients who are symptomatic following percutaneous coronary intervention, evaluating coronary artery bypass grafts and coronary stent patency, detecting coronary stenosis prior to valve surgery and assessing coronary anatomy in patients with technically difficult arterial access. Avoiding the small but definite risks of conventional coronary angiography makes cardiac computed tomography an appealing alternative. An overview of multislice computed tomography is presented with particular attention placed on its role in the risk stratification of selected patients in the perioperative period. A risk stratification algorithm is suggested.
Haemodynamic and Bispectral Index Response to Insertion of the Streamlined Liner of the Pharynx Airway (SLIPA™): Comparison with the Laryngeal Mask Airway
Authors: Puri G. D. , Hegde H. V. , Jayant A. , Bhukal I.
Published: January 2019

The newly developed supralaryngeal airway Streamlined Liner of the Pharynx Airway (SLIPA™) has been compared successfully to the LMA™, but the haemodynamic response to its insertion has not been evaluated in a randomised study. We compared haemodynamic and Bispectral index(BIS) responses to insertion of the SLIPA™ with classic LMA™ after standardising the anaesthetic technique using BIS to monitor and control the anaesthetic depth. One hundred patients were randomised to receive either a classic LMA™ or SLIPA™ following induction with fentanyl and propofol titrated to a target BIS of 40 and compared heart rate, mean arterial pressure and BIS responses to insertion. There was a significant rise in mean arterial pressure from the pre-stimulus value (73.8 [10.6] mmHg, mean ± SD) at two and three minutes (P <0.05) following insertion of the LMA™ with maximum rise (80.8 [11.5] mmHg) seen at two minutes. There was a significant rise in mean arterial pressure from the pre-stimulus value (73.2 [12.6] mmHg) atone, two, three, four and five minutes (P <0.05) following insertion of the SLIPA™ with maximum rise (86.9 [15.1] mmHg) observed at three minutes. Mean arterial pressure was significantly higher (P <0.05) with SLIPA™ at two, three, four and five minutes. BIS increased significantly (P <0.05) at one, two, three, four and five minutes following insertion of both the devices, but there was no significant difference between the groups. There was a significantly higher (P=0.001) incidence of blood on the device with the SLIPA™ (20/50 vs. 6/50 with LMA™). Thus, insertion of SLIPA™ causes significantly higher blood-pressure response but similar BIS response compared to the LMA™.
Dose-related Effect of Propofol on Pancreatic Enzymes and Triglyceride Levels in Patients Undergoing Non-abdominal Surgery
Authors: Pradeep K. , Wig J. , Panda N. B. , Prasad R.
Published: January 2019

Various case reports have indicated a possible relationship between propofol and pancreatitis. However, it is not clear whether this relationship (if any) is dose-related or idiosyncratic. Therefore, a prospective study was conducted to evaluate the effect of different doses of propofol on postoperative pancreatic enzymes and serum triglyceride levels. One hundred and fifty patients, aged 18 to 60 years, belonging to ASA physical status I and II, undergoing non-abdominal surgery were divided into three groups. Anaesthesia was induced with propofol 2 to 2.5 mg/kg in all groups. It was maintained with isoflurane in group I, propofol infusion <5 mg/kg/h in group II and propofol infusion ≥5 mg/kg/h in group III. All three groups also received nitrous oxide in oxygen for maintenance of anaesthesia. Serum amylase, lipase and triglyceride were estimated before propofol administration and at 24 and 72 hours postoperatively.

The mean values of serum amylase, lipase and triglyceride remained within the normal range in the three groups. These values did not differ significantly in between the groups even despite the significantly different doses of propofol in the three groups (P <0.001). None of the patients in the three groups developed any feature suggestive of acute pancreatitis in the postoperative period.

These findings indicate that propofol administration at recommended doses does not produce dose-related increases in pancreatic enzyme and triglyceride levels in ASA physical status I and II patients.
Users' Opinions on Intensive Care Unit Alarms — a Survey of German Intensive Care Units
Authors: Siebig S. , Sieben W. , Kollmann F. , Imhoff M. , Bruennler T. , Rockmann F. , Gather U. , Wrede C. E.
Published: January 2019

Monitoring of physiologic parameters in critically ill patients is associated with an enormous number of alarms, leading to reduced clinical value with high sensitivity but low specificity. To evaluate opinions of intensive care unit (ICU) staff on current monitoring we conducted a survey of German ICUs. Furthermore, the survey aimed to assess requirements and requests for future alarm systems.

The survey was conducted between May 2006 and June 2007 on a randomised sample of German ICUs. Questionnaires with 24 partly closed-ended partly open-ended questions were posted. Of 915 letters, 274 (30%) from 185 contacted ICUs were returned and evaluated.

One hundred and sixty physicians, the majority (52%) working in a department of anaesthesiology, and 114 nurses returned the survey. Most responders (87%) estimated that less than 50% of current alarms result in clinical consequences (52% estimated less than 25%). We suggested trend alarms, smoothing of signals to reduce artefacts, generation of new combined alarms and integrative monitoring of different alarm systems as improvements of current ICU alarm systems, all of which were agreed to by the majority. Free text commentaries focused on the need for reducing alarms caused by artefacts and called for improvement of the monitor-user interfaces.

Our survey demonstrates the dissatisfaction of clinical staff with the current alarm systems regarding alarm frequency and specificity in German ICUs, thereby confirming data raised in single institutions. ICU staff's acceptance for new alarm algorithms like signal extraction or detection of trends as a basis for smart monitoring appealed to the majority of users.
Survey of Airway Skills of Surgeons in Western Australia
Authors: Riley R. H. , Strang T. , Rao S.
Published: January 2019

Our objective was to survey all consultant surgeons, including obstetricians/gynaecologists, in the State of Western Australia to assess their experience with, and readiness to assist anaesthetists with a difficult or failed airway. Survey questionnaires were mailed to all surgeons registered in Western Australia (n=445). A total of 238 responses (53%) were received, mostly from general surgeons, obstetrician/gynaecologists and orthopaedic surgeons. Forty percent had provided non-surgical assistance with a difficult airway and 60% had assisted with a surgical airway. All ear, nose and throat surgeons who responded to the survey had assisted with an emergency surgical airway and 47 surgeons reported having performed six or more surgical airways. However, 26% of respondents had never performed a surgical airway and 37% did not feel confident in performing an urgent surgical airway. Seven percent of respondents reported witnessing a failed airway that resulted in death or neurological damage. Seventy percent of respondents had undergone formal training in tracheostomy and 26% had advanced trauma life support or early management of severe trauma training.

These findings indicate that surgeons in Western Australia perform surgical airways infrequently and only occasionally assist anaesthetists with difficult airway management. However, some surgeons lack confidence and training in surgical airway management. Because anaesthetists cannot always rely on their surgical colleagues to provide a surgical airway during a crisis, we recommend that anaesthetists discuss airway management with their surgical colleagues for all patients with identified difficult airways and that anaesthesia training should include surgical airway management.
Associations between Cerebrospinal Fluid Protein Concentrations, Serum Albumin Concentrations and Intracranial Pressure in Neurotrauma and Intracranial Haemorrhage
Authors: Jeffcote T. , Ho K. M.
Published: January 2019

Recent evidence suggests that using intravenous isotonic albumin solution for haemodynamic resuscitation in neurotrauma is associated with adverse outcomes. This study assessed the correlations between cerebrospinal fluid protein concentrations, serum albumin concentrations and intracranial pressure in a cohort of neurosurgical patients. After obtaining ethics committee approval, correlations between concomitant cerebrospinal fluid protein concentrations, serum albumin concentrations and the mean daily intracranial pressure of 63 consecutive neurosurgical patients, grouped as neurotrauma or intracranial haemorrhage, admitted between 1 January and 31 December 2007, were assessed. The mean daily intracranial pressure was significantly associated with cerebrospinal fluid protein concentrations (Spearman correlation coefficient [SCC]=0.496, P=0.001), white cell counts (SCC=0.359, P=0.001), red cell counts (SCC=0.399, P=0.001) and serum albumin concentrations (SCC=0.431, P=0.001) in patients with neurotrauma (n=23). Cerebrospinal fluid protein concentrations were also significantly associated with concomitant serum albumin concentrations (SCC=0.393, P=0.001) in these patients. In patients with intracranial haemorrhage (n=40), the mean daily intracranial pressure was only significantly associated with cerebrospinal fluid white cell and red cell counts but not cerebrospinal fluid protein and serum albumin concentrations. In summary, intracranial pressure is correlated with cerebrospinal fluid protein and serum albumin concentrations in patients with severe neurotrauma, and these suggest that blood-brain barrier may not be completely intact after severe neurotrauma.
Informed Consent for Anaesthesia in Australia and New Zealand
Authors: Braun A. R. , Skene L. , Merry A. F.
Published: January 2019

The legal and ethical requirements related to an anaesthetist's communication with patients in preparing them for anaesthesia, assisting them in making appropriate decisions and obtaining consent in a formal sense are complex. Doing these things well takes time, skill and sensitivity. The primary focus should be to adequately prepare patients for surgery and to ensure that they are sufficiently well informed to make the choices that best meet their own needs. This is just an affirmation of the importance of patient-centred care.
Randomised Comparison of the LMA Supreme™ with the I-Gel™ in Spontaneously Breathing Anaesthetised Adult Patients
Authors: Chew E. F. F. , Hashim N. H. M. , Wang C. Y.
Published: January 2019

We compared the performance of the LMA Supreme™ (SLMA) with the I-Gel™ during anaesthesia in spontaneously breathing adult patients. Ninety patients with American Society of Anesthesiologists physical status I or II were studied in a prospective randomised controlled study. Our primary outcome measure was oropharyngeal leak pressure. We also compared the overall insertion success rate, ease of insertion, adequacy of ventilation and incidence of complications. The mean (SD) oropharyngeal leak pressure for the SLMA was 25.6 (5.1) cmH2O, which was greater than for the I-Gel 20.7 (5.9) cmH2O (P=0.0001). The first attempt and overall insertion success rates were similar between the two groups (SLMA 97.8 and 97.8%; I-Gel 93.3 and 100%, P=0.132). The SLMA was rated easier to insert than the I-Gel (P=0.011), but the time taken for insertion (P=0.433) was similar. The incidence of complications was low in both groups. The grade of fibreoptic view was better with the I-Gel than the SLMA (P=0.001). We conclude that in adults with normal airways, the SLMA is easier to insert and provides a higher oropharyngeal leak pressure. but fibreoptic views are better with the i-gel.
The Effect of Recorded Maternal Voice on Perioperative Anxiety and Emergence in Children
Authors: Kim S. J. , Oh Y. J. , Kim K. J. , Kwak Y.-L. , Na S.
Published: January 2019

This study was performed to test if hearing a recorded maternal voice reduces anxiety, emergence agitation and anaesthetic requirements in children. With written informed consent, children scheduled for cardiac catheterisation under intravenous ketamine anaesthesia and their mothers (n=46) were randomly assigned to either the mother-voice (MV) or control group. While the MV group (n=23) listened via headphones to a recording of their mothers’ voices during the perioperative period, the control group (n=23) wore headphones with no auditory stimulation. Ketamine requirements and haemodynamics were recorded. Anxiety of the patients and the parents were measured before and after the procedure with the modified Yale preoperative anxiety scale and Spielberger's State-Trait Anxiety Inventory, respectively. Emergence agitation was graded. The demographic and haemodynamic data were comparable, except for a longer procedure time in the MV group. Mothers’ State-Trait Anxiety Inventory was not different preoperatively between the groups. Mothers’ state and trait anxiety was lower after the procedure in the MV group compared with the preoperative values. In the control group only maternal state anxiety was diminished after the procedure. There was no significant group difference with respect to ketamine requirement (5.1±1.9 mg vs 4.9±1.6 mg, P=0.645). The anxiety score of children was lower in the MV group before the procedure (modified Yale preoperative anxiety scale score 35±12 vs 28±9, P=0.038), but there was no significant difference postoperatively. Emergence agitation was attenuated in the MV group (P=0.005).
Effect of Preoperative Education on Behaviour of Children during Induction of Anaesthesia: A Randomised Clinical Trial of Efficacy
Authors: Hee H. I. , Lim E. H. L. , Tan Q. C. , Bao Z. Y. , Loh K. W. T.
Published: January 2019

In this randomised prospective study we aimed to evaluate whether preoperative anaesthetic education delivered to children on the day of surgery reduces anxiety behaviour during induction of anaesthesia. One hundred children, six to 15 years of age, undergoing general anaesthesia for ambulatory surgery were allocated at random to a preoperative education group (n=50) or a control group (n=50). The main outcomes were behaviour score, self-reporting of satisfaction score and identification of the stage when children felt most fearful. Data from all 100 participants were analysed. There was no difference in behaviour score at induction or satisfaction score between the groups. Eighteen percent in the intervention group reported no fear preoperatively vs 10% in the control group. Intravenous induction failed in nine out of 38 children in the intervention group (23.7%) compared to five out of 40 in the control group (12.5%). When intravenous induction failed, eight out of nine (89%) of the intervention group remained co-operative during gas induction compared to two out of five (40%) of the control group. Preoperative education delivered on the day of surgery did not reduce anxiety behaviour in children during intravenous induction of anaesthesia, but did reduce anxiety during subsequent inhalational induction.
A Survey of Anaesthetists’ Understanding of Australian Mandatory Reporting Laws
Authors: Griffiths S. E. , Burke J. A.
Published: January 2019

Australian mandatory reporting laws for healthcare practitioners were introduced nationally in July 2010. We distributed an online survey to specialist anaesthetists and anaesthesia trainees in our institution with the aim of assessing anaesthetists’ awareness, understanding and interpretation of the new laws. One hundred and three completed responses were received (response rate 67%). The majority of respondents were aware of their professional (85%) and legal (68%) reporting obligations. Respondents were most likely to report conduct relating to alcohol intoxication or sexual misconduct (75%) and least likely to report a colleague with an impairment that may be placing the public at risk of harm (12%). Consultant anaesthetists were more likely than trainees to report students (P=0.002), junior colleagues (P=0.01) and senior colleagues (P=0.03). Some anaesthetists believed the laws would deter them from seeking medical help themselves if they were impaired (39%). Mandatory reporting laws aim to improve patient safety while being fair to doctors who are reported and protecting those who report. Our survey indicates that there are differences among anaesthetists about the type of conduct they would report and their perception of the consequences of making a report.
Limited Sampling Strategy for Estimation of Amikacin Optimal Sampling Time in Critically Ill Adults
Authors: Mahmoudi L. , Mohammadpour A. H. , Niknam R. , Ahmadi A. , Mojtahedzadeh M.
Published: January 2019

Aminoglycosides are a class of antibiotics that are commonly used in the treatment of gram-negative pathogens in the critically ill population. Unfortunately, dosing of these aminoglycosides in critically ill patients is difficult due to their altered pharmacokinetics in the critically ill and narrow therapeutic index. In this study, we evaluated whether a limited sampling strategy can be used to predict the area under the concentration (AUC) curve of amikacin concentrations over a 24-hour period after a single dose of intravenous amikacin (25 mg/kg). This open-labelled, non-comparative prospective study recruited 20 adult critically ill trauma patients with a diagnosis of hospital-acquired infection. We assessed the best estimate of plasma amikacin concentrations over a 24-hour period by multiple stepwise regression, using nine blood samples during this study period as the gold standard. Using a jackknife procedure, the AUC of amikacin over a 24-hour period was estimated by choosing a combination of the amikacin concentrations measured at different time-points. Overall, the mean prediction error of all models was not statistically different from zero ( P >0.05). Based on bias and imprecision, all models gave good estimate of AUC of amikacin over a 24-hour period, but a two-point sampling strategy at 1.5 and 6 hours post-dose appeared to offer the best compromise between accuracy and cost-effectiveness in optimising the dosing of amikacin in critically ill patients.
An assessment of two Doppler-Based Monitors to Track Cardiac Output Changes in Anaesthetised Patients Undergoing Major Surgery
Authors: Huang L. , Critchley L. A. H.
Published: January 2019

Minimally-invasive cardiac output (CO) monitoring to follow changes in CO would be helpful in anaesthesia practice. Two Doppler systems marketed for this purpose include the CardioQ (Deltex Medical Group, Chichester, United Kingdom), which uses an oesophageal probe, and the USCOM (USCOM Ltd., Sydney, NSW, Australia), which uses a hand-held probe. The aim of the study was to assess the ability of these two methods to track CO during major surgery and to determine their relationship. Twenty patients, age 58 (26 to 81) years, (m/f) 15/5, requiring abdominal surgery were studied. The surgical procedures lasted between 128 and 408 minutes and a total of 285 data pairs (8 to 22 per case) were collected. Time plots showed good tracking ability across a wide range of CO in most patients. Correlation between the two devices was excellent in 14 patients (R2 >0.85), good in another four (R2 >0.64) and poor in two. Regression line data supported the hypothesis that CardioQ under-reads at low CO and over-reads at high CO in respect to the USCOM. However, the precision between the two CO readings was poor with wide limits of agreement and a percentage error of ± 37%. These findings indicate that these devices individually track changes in CO in many patients but cannot be relied upon to provide the same values.
Patient-Level Interventions to Prevent the Acquisition of Resistant Gram-Negative Bacteria in Critically Ill Patients: A Systematic Review
Authors: Zaky A. , Zeliadt S. B. , Treggiari M. M.
Published: January 2019

The rising incidence of multidrug-resistant Gram-negative bacterial (MDR-GNB) infections acquired in intensive care units has prompted a variety of patient-level infection control efforts. However, it is not known whether these measures are effective in reducing colonisation and infection. The purpose of this systematic review was to assess the efficacy of patient-level interventions for the prevention of colonisation with MDR-GNB and whether these interventions are associated with a reduction in the rate of infection due to MDR-GNB in the intensive care unit. Searches were conducted on PubMed, Cochrane, EMBASE and World of Science databases to identify comparative interventional studies on patient-level interventions implemented in the intensive care unit. Literature published in English, Spanish or French from January 1, 2000, until April 30, 2013, was searched. A total of 631 reports were found and we included and analysed 13 comparative studies that reported outcomes for an intervention compared with a control group. There were ten randomised and three observational interventional trials evaluating seven interventions. Overall, there was a reduction in colonisation (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.66 to 0.85) and infection (OR 0.66; 95% CI 0.59 to 0.75) with MDR-GNB. This trend persisted after restricting pooled analysis to randomised controlled trials (pooled OR 0.66; 95% CI 0.57 to 0.76 and pooled OR 0.62; 95% CI 0.54 to 0.72, respectively). We identified a significant reduction in MDR-GNB colonisation and infection through the use of patient-level interventions. This effect was mostly accounted for by selective digestive decontamination. However, given the limitations of the analysed trials, adequately powered controlled studies are needed to further explore the effects of patient-level interventions on colonisation and infection with MDR-GNB.
The Prevention of Second Anaphylactoid Reactions to Anaesthetic Drugs
Authors: Fisher M. McD.
Published: January 2019

Fourteen patients who had second reactions to anaesthetic drugs are described. These reactions occurred for various reasons: attributing the initial reaction to the wrong drug, failure to appreciate the possibility of cross sensitivity, and failure to investigate the reaction and explain the reaction fully to the patient.

With adequate investigation, communication and avoidance of drugs responsible, use of pretreatment and alternative techniques, the risk of second reactions should be reduced.
Changes of Body Temperature and Heat in Cardiac Surgical Patients
Authors: Shanks Colin A. , Wade Leonard D. , Meyer Ronald , Wilkinson Carolyn J.
Published: January 2019

Changes in body temperature were assessed in ten adult patients undergoing surgery involving cardiopulmonary bypass (CPB) and induced hypothermia. Intraoperatively, in comparable time intervals before CPB and after rewarming, the patients lost body heat. Between the time of induction of anaesthesia and CPB, the temperature of blood in the pulmonary artery fell 1.46 (SD 0.28°C); between CPB and the end of surgery the fall was 1.55 (SD 0.86°C). The extent of spontaneous hypothermia did not correlate with the amount of subcutaneous fat.

Hypothermia was induced to obtain a stable deep body temperature of 27.2 (SD 1.3)°C, when mean skin temperature averaged 2°C higher. The CPB machine returned approximately 2000 kJ of heat in the rewarming period, to produce pulmonary artery and mean skin temperatures of 37.1 (SD 0.7)°C and 31.4 (SD 2.1)°C respectively. Intraoperative deep body temperatures demonstrated the expected exponential relationship with metabolic rate. Postoperatively, increase in metabolic rate was associated with rising deep body and skin temperatures. Low resistance to the flow of heat toward the skin surface was demonstrated by low postoperative values for thermal insulation, which may indicate good peripheral perfusion seen during continuing vasodilator therapy.
Postoperative Neuromuscular Function
Authors: Beemer G. H. , Rozental P.
Published: January 2019

One hundred patients who received a competitive neuromuscular blocking agent during anaesthesia were randomly selected for evaluation of neuromuscular function immediately on their arrival in the recovery room. The anaesthetist was not aware that the patient would be evaluated in the recovery room. Neuromuscular function was assessed by a train-of-four (TOF) ratio, and in conscious and co-operative patients by a series of bedside tests of neuromuscular function. Twenty-one patients had a TOF ratio of less than 0.70 and seven patients a TOF ratio of less than 0.60. Bedside tests of neuromuscular function did not reliably detect this defect in neuromuscular transmission. It is concluded that a relatively large number of patients have a defect in neuromuscular transmission on their arrival in the recovery room, and suggested that this reflects the inadequacy of clinical methods used for the administration and antagonism of competitive neuromuscular blocking agents at this institution.
Opiate Receptors: An Introduction
Authors: Carmody J. J.
Published: January 2019

Current status of opiate receptors and their agonists is reviewed — basic aspects of receptor theory, the importance of stereospecificity in drug-receptor interactions and the role of ‘second messengers’ in drug action. The three classes of endogenous opioids, originating from three distinct genes, are discussed: pro-opiomelanocortin, giving rise to β-endorphin, ACTH and various MSHs; pro-enkephalin, giving methionine enkephalin and leucine enkephalin; and prodynorphin; their anatomical distribution and the main classes of receptors with which they interact, the μ-receptor, with a high affinity for met-enkephalin and β-endorphin (as well as morphine and dynorphin A); the δ-receptor for which the primary ligand is leu-enkephalin; and the χ-receptor which is the main target for the dynorphins. Functional roles for endogenous opioids are considered. Essentially they are inhibitory to target neurones, depressing motor reflexes, baroreflexes and nociception. They also have roles in the response to physical and psychological stress.
An Evaluation of Five Carbon Dioxide Analysers for use in the Operating Theatre and Intensive Care Unit
Authors: Selby D. G. , Ilsley A. H. , Runciman W. B.
Published: January 2019

Five commercially available carbon dioxide analysers were assessed with respect to accuracy, response time, stability, the effect of water vapour and the effect of rebreathing. Two side-stream sampling analysers (Datex Normocap and Engstrom Eliza) and one main-stream sampling analyser (Hewlett-Packard Capnoshot) were found to be satisfactory for use both in the operating theatre and intensive care unit. The Instrumentation Laboratory (IL) 200, a side-stream monitor, performed satisfactorily but neither it nor the Siemens Sirecust 404, a main-stream monitor, has the facility to compensate for the presence of nitrous oxide. The Siemens analyser, in the form tested, could not be recommended for clinical use, as it was less accurate than the other monitors, could not detect rebreathing, and was subject to fluctuations when used with gas mixtures saturated with water vapour.
Septic Shock: Does Adrenaline have a Role as a First-line Inotropic Agent?
Authors: Wilson W. , Lipman J. , Scribante J. , Kobilski S. , Lee C. , Krause P. , Cooper J. , Barr J.
Published: January 2019

Fifteen adult patients, admitted to Baragwanath Hospital ICU with septic shock after adequate fluid loading and on no other inotropic agents, were given adrenaline in incremental doses. Oxygen transport and haemodynamic variables were monitored with each dose increment until a systolic blood pressure of 120 mmHg was obtained. This was reached on an average dose of adrenaline of 0.16±0.02 μg/kg/min. Mean arterial blood pressure increased by 22±2 mmHg mainly due to an increase in cardiac index (1±0.2 l/min/m2) and systemic vascular resistance index (130±41 dyn.s.cm.-5m-2) with a small increase in heart rate of 8±3 beats per minute. Oxygen delivery was increased with no significant increase in oxygen consumption and lactate levels increased. Adrenaline is therefore an effective initial inotropic agent. Patients may respond to lower doses than when used concurrently with other inotropic agents but there was still a significant dose variation in response. We cannot, however, exclude a deleterious effect on oxygen utilization.
Propofol Induction for Laryngeal Mask Airway Insertion: Dose Requirement and Cardiorespiratory Effects
Authors: Blake D. W. , Dawson P. , Donnan G. , Bjorksten A.
Published: January 2019

The dosage, haemodynamic and respiratory effects of propofol for laryngeal mask airway (LMA) insertion were investigated. Fifty patients (ASA I-II) were randomly assigned one of four induction doses of propofol (1.5–2.5 mg/kg) delivered over 30 seconds and the first attempt at LMA insertion was made at 90 seconds. The LMA was inserted at 90 seconds in 35 patients and by 300 seconds in 13 others (mean plasma concentration at 90 seconds was 7.7 mcg/ml (no delay) versus 5.2 mcg/ml (insertion delayed), P < 0.01). Insertion was less successful after 1.5 mcg/kg (failed at 90 seconds in 6 of 12 patients), but did not vary with the other doses. Additional propofol (0.5 mg/kg/30s) was required in 22 patients for LMA insertion or to prevent movement, resulting in propofol concentrations at 120–180 seconds above 7 mcg/ml. Respiratory effects were minor, but MAP decreased by 18±1.4 mmHg at 90 seconds. Cardiovascular effects did not differ significantly between dosage groups or with the use of additional propofol.
A Clinical Evaluation of the Hemocue Haemoglobinometer using Capillary, Venous and Arterial Samples
Authors: Chen P. P. , Short T. G. , Leung D. H. Y. , Oh T. E.
Published: January 2019

The ‘Hemocue’ device for rapid estimation of haemoglobin concentration was evaluated in a clinical setting. Repeatable accuracy of capillary, venous and arterial samples was examined and then compared with standard laboratory venous haemoglobin estimates using a ‘Coulter JT analyser in 42 patients. The mean values for haemoglobin (g/l) and coefficient of variation were capillary 108.2 (8.0); venous 104.9 (2.2); arterial 105.9 (2.0); and laboratory venous 104.6 (1.3). Although the mean haemoglobin values were similar, capillary samples were significantly less repeatable than venous or arterial samples (Pitman test, P < 0.001). Comparison of variance between the laboratory sample and each sampling technique demonstrated that capillary samples were significantly more variable than venous or arterial samples. Peripheral skin temperature did not influence the accuracy of capillary samples. Hemocue estimations of venous samples were found to be as accurate as laboratory estimations. The lack of repeatable accuracy of capillary estimations was sufficiently large that their use cannot be recommended in clinical practice.
Intensive Care Utilisation: The Baragwanath Experience
Authors: Marik P. E. , Kraus P. , Lipman J.
Published: January 2019

Intensive care medicine is an expensive service whose impact on health care has been questioned. South Africa is a country undergoing rapid social and political change and the role of intensive care medicine in the health care system of this country needs to be assessed. In this paper we evaluated the quality, cost-effectiveness and utilisation of technology in the intensive care unit of Baragwanath Hospital, a hospital serving the black community of Soweto.
A National Survey of Atropine Use by Australian Anaesthetists
Authors: Parnis S. J. , Van Der Walt J. H.
Published: January 2019

All Fellows of the Faculty of Anaesthetists, Royal Australasian College of Surgeons (now Australian and New Zealand College of Anaesthetists) were surveyed by mail regarding their use of prophylactic atropine. They were asked whether their usual practice was to give atropine for the following indications: premedication, induction of anaesthesia, intubation of the trachea, one dose of suxamethonium, a second dose of suxamethonium, halothane anaesthesia, oropharyngeal surgery, bronchoscopy and eye surgery. For each indication they were asked for details regarding their practice concerning neonates, infants, children and adults. The large response rate of 86% of Fellows returning a survey form ensured that the survey was representative of Australian anaesthetic practice. Results indicate a wide variation in practice regarding the prophylactic use of atropine, with neonates, infants and children more likely to receive prophylactic atropine than adults. The majority do not give prophylactic atropine as premedication, but may give it in the younger age groups at induction, and many (67%) only give it if they are to administer suxamethonium to a child. The only indication for which a convincing majority (>80%) of anaesthetists agreed that prophylactic atropine should be given was when a repeated dose of suxamethonium was to be given to neonates, infants or children. A large proportion of anaesthetists (>80%) agreed that atropine is not necessary prior to halothane anaesthesia in all age groups, nor as premedication, at induction, at intubation, prior to oropharyngeal surgery or prior to eye surgery in adults. These results were compared with the practice at a major paediatric hospital where the practice is not to use routine prophylactic atropine.
A Simple Method of Bronchoalveolar Lavage
Authors: Schindler M. B. , Cox P. N.
Published: January 2019

Twenty-eight ventilated paediatric intensive care patients, mean age 4.1 ± 4 years, who had had a simple method of non-bronchoscopic bronchoalveolar lavage (NB-BAL) performed were reviewed. The NB-BAL technique involved blindly wedging a 5 or 8F infant feeding catheter endobronchially and lavaging one millilitre per kg saline using a syringe.

Adequate samples were collected in 87% of the NB-BAL specimens. In two of the four inadequate specimens, Pneumocystis carinii was still able to be identified. Additional information not obtained from the tracheal aspirate culture was seen in 71% of the NB-BAL samples. One-third of the patients also had a bronchoscopic BAL or a lung biopsy performed and the culture results were all identical to those obtained from NB-BAL. No significant complications were seen. Oxygenation and ventilation were not altered by the technique.

We conclude that NB-BAL performed using a syringe and infant feeding catheter is a simple and cheap method that produces good alveolar samples in the majority of cases.
Auditory Recall and Response to Command during Recovery from Propofol Anaesthesia
Authors: Williams M. L. , Sleigh J. W.
Published: January 2019

Most studies of awareness under general anaesthesia use the ability to respond to a verbal command as the primary measure of consciousness. The aim of this pilot study was to discover whether it was possible for subjects recovering from a propofol general anaesthetic to experience conscious awareness without the capability of responding to verbal command. Ten healthy volunteers received an intravenous propofol infusion (1500 mg/hr) until they were no longer conscious. The infusion was then stopped and they were given verbal commands interspersed with random numbers from a recorded tape until they were able to respond appropriately. Seven of the subjects were able to remember numbers corresponding to times 10 to 40 seconds before they responded to verbal command. In none of these subjects was there recall of the number 30 minutes later.

We concluded that there is an ability to have conscious awareness of auditory input without necessarily being able to demonstrate this by responding to verbal command.
Recent Experiences with Hexadimethrine for Neutralizing Heparin after Cardiopulmonary Bypass
Authors: Cooney A. , Mann T. J.
Published: January 2019

Hexadimethrine bromide was used for the neutralization of heparin during cardiac surgery in the late 1950s. For some years, this institution has used it for patients who may be allergic to protamine. In view of the recent renewal of interest in hexadimethrine, we present four cases outlining its use during cardiac procedures in such patients. Other drugs for reversing the action of heparin such as heparinase or platelet factor IV are not yet widely available.
Combined Spinal-Epidural Analgesia in the Management of Labouring Parturients with Mitral Stenosis
Authors: Kee W. D. Ngan , Shen J. , Chiu A. T. O. , Lok I. , Khaw K. S.
Published: January 2019

We report the use of combined spinal-epidural analgesia during labour in three parturients with moderately severe mitral stenosis. In each case, rapid analgesia was achieved using intrathecal fentanyl 25 μg without major haemodynamic changes. Maintenance analgesia was then established gradually using a dilute epidural infusion of bupivacaine 0.1% and fentanyl 0.0002%, with the avoidance of large or rapid boluses of local anaesthetic. Supplementary analgesia in the latter stages of labour was provided using slow epidural boluses of fentanyl, with or without a low concentration of bupivacaine, which was sufficient to allow controlled instrumental deliveries. We conclude that combined spinal-epidural analgesia is a useful technique for providing analgesia and maintaining haemodynamic stability in parturients with mitral stenosis.