bluuebunny/crossref_metadata_2025 huggingface dataset:
Knotted Femoral Nerve Catheter
Authors: Rudd K. , Hall P. J.
Published: January 2019

We describe a case of knotting of a femoral nerve catheter which prevented removal by traction after knee replacement surgery. In this context, early surgical removal should be performed as bacterial colonization of femoral catheters is common. Radiological imaging of the catheter may assist decision-making about whether to persist with traction and what surgical approach is required. Minimizing the length of catheter inserted to less than 10 cm makes knotting unlikely, but will decrease the chance of achieving lumbar plexus blockade which could improve analgesia if the catheter passes centrally.
Activated Protein C for the Treatment of Fulminant Meningococcal Septicaemia
Authors: Thomas G. L. , Wigmore T. , Clark P.
Published: January 2019

We report two cases of meningococcal septic shock with multiple organ failure treated with prompt administration of activated protein C. This was associated with a rapid clinical improvement and early cessation of organ support. Both patients survived to hospital discharge with no long-term sequelae.
Use of Intrathecal Neostigmine as an Adjunct to Other Spinal Medications in Perioperative and Peripartum Analgesia: A Meta-analysis
Authors: Ho K. M. , Ismail H. , Lee K. C. , Branch R.
Published: January 2019

Intrathecal neostigmine has been used as an adjunct to intrathecal local anaesthetic or opioid to prolong regional analgesia and improve haemodynamic stability, with variable results. This meta-analysis aims to evaluate the effectiveness and side-effects of intrathecal neostigmine in the perioperative and peripartum settings. The literature search was based on Cochrane Controlled Trials Register, EMBASE and MEDLINE (from 1966 to 14 November 2003) databases. Volunteer and animal studies were excluded. We identified 26 studies and 19 were considered suitable for detailed data extraction. Intrathecal neostigmine increased the incidence of nausea and vomiting (OR 5.0, 95% CI: 3.4 to 7.3; P<0.00001), bradycardia requiring intravenous atropine (OR 2.7, 95% CI: 1.4 to 5.4; P=0.005), and anxiety, agitation, or restlessness (OR 10.3, 95% CI: 3.7 to 28.9; P=0.00001). It improved the overall 24 hour VAS score (–1.4 VAS pain score, 95% CI: -1.7 to -1.2, P<0.00001), delayed the time of first request for rescue analgesia (168 min, 95% CI: 125 to 211; P<0.00001), and reduced the total number of rescue injections of nonsteroidal anti-inflammatory drug within the first 24 hours (-0.8, 95% CI: -1.1 to -0.4; P=0.00001). It did not affect the duration of motor blockade (3.5 min, 95% CI: -1.5 to 8.6; P=0.17) or the total amount of ephedrine required (-0.4 mg, 95% CI: -1.5 to 0.7; P=0.5). Adding intrathecal neostigmine to other spinal medications improves perioperative and peripartum analgesia marginally when compared with placebo. It is associated with significant side-effects and the disadvantages outweigh the minor improvement in analgesia achieved.
Spinal-induced Hypotension in Elderly Patients with Hip Fracture. A Comparison of Glucose-free Bupivacaine with Glucose-free Bupivacaine and Fentanyl
Authors: Martyr J. W. , Stannard K. J. D. , Gillespie G.
Published: January 2019

Intraoperative hypotension is a common and potentially deleterious event in elderly patients undergoing spinal anaesthesia for repair of hip fractures. The synergism between intrathecal opioids and local anaesthetics may allow a reduction in the dose of local anaesthetic and cause less sympathetic block and hypotension, while still maintaining adequate anaesthesia. We studied 40 elderly patients having either an insertion of a dynamic hip screw or a hemi-arthroplasty and compared 9.0 mg glucose-free bupivacaine with added fentanyl 20 μg (group BF) with 11.0 m glucose-free bupivacaine alone (group B). Hypotension was defined as a fall in systolic blood pressure to less than 75% baseline or less than 90 mmHg. The incidence and frequency of hypotension in group BF were less than in group B. Similarly, falls in systolic, diastolic and mean blood pressures were all less in group BF than in group B. However, there were four failed blocks in group BF and one in group B.
Recombinant Activated Factor VIIa Use in Massive Transfusion and Coagulopathy Unresponsive to Conventional Therapy
Authors: Gowers C. J. D. , Parr M. J. A.
Published: January 2019

We report a retrospective analysis of patients admitted to a tertiary intensive care unit who received recombinant activated factor VIIa (rFVIIa) in an effort to control life-threatening haemorrhage and coagulopathy. Data extracted included: demographics, diagnoses and clinical course, dosage of rFVIIa, blood product requirements and coagulation tests prior to and after rFVIIa, pH, base deficit and temperature. During the study period rFVIIa was given to nine patients with refractory coagulopathy in imminent danger of death. Three patients were post cardiac surgery, three patients had multiple blunt trauma, one patient had a close range shotgun wound to the abdomen, one patient had a ruptured iliac artery aneurysm and one patient was post caesarean section with acute fatty liver of pregnancy. Improvements in prothrombin time (PT) (median 17s pre vs 10.6s post rFVIIa (P<0.05)) were seen in all nine cases. Reduced requirements for red blood cells, fresh frozen plasma, platelets and cryoprecipitate followed rFVIIa administration in eight cases. One patient died after 48 hours of complications unrelated to the initial pathology. Seven patients were discharged from hospital; one remains in hospital. rFVIIa provided improvement in coagulopathy unresponsive to conventional therapy.
A Novel Technique for Post-pyloric Feeding Tube Placement in Critically Ill Patients: A Pilot Study
Authors: Young R. J. , Chapman M. J. , Fraser R. , Vozzo R. , Chorley D. P. , Creed S.
Published: January 2019

Delivery of enteral nutrition in critically ill patients is often hampered by gastric stasis necessitating direct feeding into the small intestine. Current techniques for placement of post-pyloric feeding catheters are complex, time consuming or both, and improvements in feeding tube placement techniques are required. The Cathlocator™ is a novel device that permits real time localisation of the end of feeding tubes via detection of a magnetic field generated by a small electric current in a coil incorporated in the tip of the tube. We performed a pilot study evaluating the feasibility of the Cathlocator™ system to guide and evaluate the placement of (1) nasoduodenal feeding tubes, and (2) nasogastric drainage tubes in critically ill patients with feed intolerance due to slow gastric emptying. A prospective study of eight critically ill patients was undertaken in the intensive care unit of a tertiary hospital. The Cathlocator™ was used to (1) guide the positioning of the tubes post-pylorically and (2) determine whether nasogastric and nasoduodenal tubes were placed correctly. Tube tip position was compared with data obtained by radiology. Data are expressed as median (range). Duodenal tube placement was successful in 7 of 8 patients (insertion time 12.6 min (5.3–34.4)). All nasogastric tube placements were successful (insertion time 3.4 min (0.6–10.0)). The Cathlocator™ accurately determined the position of both tubes without complication in all cases. The Cathlocator™ allows placement and location of an enteral feeding tube in real time in critically ill patients with slow gastric emptying. These findings warrant further studies into the application of this technique for placement of post-pyloric feeding tubes.
A Comparison of the GlideScope® with the Macintosh Laryngoscope for Tracheal Intubation in Patients with Simulated Difficult Airway
Authors: Lim Y. , Yeo S. W.
Published: January 2019

We compared the use of the GlideScope® and the conventional Macintosh laryngoscope in a simulated difficult airway. The primary hypothesis was that time to intubation would be shorter using the GlideScope® than using the Macintosh laryngoscope.

After obtaining approval from the ethics committee and written informed consent, we recruited 60 ASA 1 and 2 patients to our randomized controlled trial. Group G (n=30) had tracheal intubation performed using the GlideScope® and Group M (n=30) were intubated using a Macintosh laryngoscope. We simulated a difficult airway in each patient by having an experienced assistant provide in-line manual stabilization of the head and neck. We recorded the best laryngeal view; difficulty of the tracheal intubation; time taken for successful tracheal intubation; manoeuvre needed to aid tracheal intubation and complications associated with the tracheal intubation.

The median Cormack and Lehane grade was significantly better in Group G than Group M. Group G had a significantly shorter intubation time than group M (mean 41.8s±SD 20.2 vs mean 56.2s±26.6, P<0.05).

The GlideScope® improved the laryngeal view and decreased time for tracheal intubation time when compared with the Macintosh laryngoscope in patients with simulated difficult airway. The GlideScope® may be a good alternative for managing the difficult airway but clinical trials evaluating its use on patients with an actual difficult airway are needed.
Intra- and Extra-pericardial Lengths of the Superior Vena Cava in Vivo: Implication for the Positioning of Central Venous Catheters
Authors: Kwon T. D. , Kim K. H. , Ryu H. G. , Jung C. W. , Goo J. M. , Bahk J. H.
Published: January 2019

To reduce the possibility of cardiac tamponade, a rare but lethal complication of central venous catheters, the tip of the central venous catheter should be located above the cephalic limit of the pericardial reflection, not only above the superior vena cava-right atrium junction. This study was performed to measure the superior vena cava lengths above and below the pericardial reflection in cardiac surgical patients. Cardiac surgical patients (n=61; 27 male), whose age [mean±SD (range)] was 47±15 (15–75) years, were studied. The intrapericardial and extrapericardial lengths, and the length of the medial duplicated part were measured separately. The whole vertical lengths of the superior vena cava on either side were calculated respectively by adding the intra-and extrapericardial and medial duplication lengths. The lateral extrapericardial was 29.1±6.5 (Mean±SD) (9–49) mm (range), and lateral extrapericardial length was 32.6±6.9 (20–53) mm. The medial extrapericardial length was 23.3±5.0 (11–39) mm, medical duplicated length was 7.2±3.3 (4–20) mm, and medial intrapericardial was 28.3±7.0 (20–52) mm. The averaged superior vena cava length of both sides was 60.3±9.0 (44.5–90) mm. Almost half of the superior vena cava was found to be within the pericardium and half out. This information may be helpful in deciding how far a central venous catheter should be withdrawn beyond the superior vena cava-right atrial junction during right atrial electrocardiographic guided insertion, and in the prediction of optimal central venous catheter insertion depth.
Heparin-induced Thrombocytopenia and the Use of r-Hirudin during Cardiopulmonary Bypass
Authors: Manikappa S. , Benfield K. , Gan T. E. , Butler J. , Malan E. , Tran H. A. M. , Tucker A.
Published: January 2019

We report the successful use of r-hirudin (lepirudin) for cardiopulmonary bypass in a 67-year-old man who developed heparin-induced thrombocytopenia type II during heparin treatment of an extensive deep venous thrombosis. Lepirudin was monitored by the modified ecarin clotting time in a “mobile laboratory” set up next to the cardiac theatre, aiming for lepirudin levels of 3.5 to 4.5 μg/ml during bypass.
The Impact of an ICU Liaison Nurse on Discharge Delay in Patients after Prolonged ICU Stay
Authors: Chaboyer W. , Thalib L. , Foster M. , Elliott D. , Endacott R. , Richards B.
Published: January 2019

The mismatch between intensive care unit (ICU) bed availability and demand may be improved with timely patient discharges, however little is known about the nature and contributing factors of discharge delays. This study investigated the impact of a specific intervention—the ICU liaison nurse role—in reducing ICU discharge delay using a prospective block intervention study. One hundred and eighty-six ICU patients (101 control and 85 liaison nurse intervention) with an ICU length of stay of three days or longer and who survived to ICU discharge were examined. The liaison nurse was involved in assessment of patients for transfer to the ward, with a major focus on coordinating patient transfer including liaison with ward staff prior to and following ICU discharge. Logistic regression was used to quantify the risk of discharge delay associated with the liaison nurse intervention with adjustment for potential confounding variables. While no demographic or clinical variables were significant predictors of ICU discharge delay, those in the liaison nurse group were almost three times less likely to experience a discharge delay of at least two hours and about 2.5 times less likely to experience a delay of four or more hours. The positive effect of the liaison nurse role in reducing the discharge delay remained after adjusting for potential confounders. We conclude that the liaison nurse role is effective in reducing the discharge delay in ICU transfer.
Effectiveness of 3-in-1 Continuous Femoral Block of Differing Concentrations Compared to Patient Controlled Intravenous Morphine for Post Total Knee Arthroplasty Analgesia and Knee Rehabilitation
Authors: Seet E. , Leong W. L. , Yeo A. S. N. , Fook-Chong S.
Published: January 2019

We assessed the effectiveness of the 3-in-l continuous femoral block as a form of postoperative pain relief for unilateral total knee arthroplasty (TKA). Sixty patients undergoing elective unilateral TKA under subarachnoid block were randomized into three groups. Postoperative analgesia was provided with a continuous 3-in-l femoral nerve catheter with 0.15% ropivacaine in group A, a continuous 3-in-l femoral nerve catheter with 0.2% ropivacaine in group B, or patient controlled intravenous morphine in group C (control group). Groups A and B received patient controlled intravenous morphine pumps for rescue analgesia. Patients in each group were followed for 72 hours postoperatively. Five patients were excluded after randomization. In the remaining 55 patients there was no statistical difference in pain score between the groups. Total morphine use was highest in group C (P< 0.05). No appreciable difference could be found with sensorimotor blockade, morphine usage and satisfaction scores when comparing groups A and B. Femoral catheter dislodgement rate was 7.9%. There was no statistical difference between the groups when comparing the day of first ambulation and the time to discharge from the hospital. Satisfaction scores were higher in group A (P = 0.028) and group B (P = 0.002) compared to group C. We conclude that a continuous 3-in-l femoral nerve block with ropivacaine 0.15% or 0.2% for elective unilateral TKA has an opioid-sparing effect.
The Use of Recombinant Activated Factor VII for Refractory Bleeding Post Complex Cardiothoracic Surgery
Authors: Walsham J. , Fraser J. F. , Mullany D. , Ziegenfus M. , Chinthamuneedi M , Dunning J. , Tesar P.
Published: January 2019

We reviewed the outcome following use of recombinant activated factor VII (rVIIa) in patients with major bleeding post cardiothoracic surgery in our unit between January 2002 and July 2004. The unit consists of 16 cardiothoracic intensive care beds in a public metropolitan teaching hospital which serves as a referral centre for heart and lung transplant surgery. Patients with refractory bleeding following cardiothoracic surgical procedures who were treated with rVIIa were identified. A total of 12 episodes of rVIIa use were recorded in ten patients, including three episodes with ventricular assist devices, and 5 heart and/or lung transplants. The median dose used was 85 μg/kg. Chest tube drainage decreased in all patients following administration of rVIIa; median chest tube drainage decreased from 445 ml/h to 171 ml/h (P=0.03). Despite cessation of bleeding, mortality was high when rVIIa was used after more than 24 hours. In six episodes, despite early rVIIa use (within six hours), continued bleeding necessitated return to theatre, where a surgical source of bleeding was found. In this small retrospective study, rVIIa significantly reduced bleeding that was refractory to standard blood product transfusion. In this series of patients, those that did not respond to rVIIa early in the postoperative phase were found to have a surgical source of bleeding.
Laryngotracheal Hypoplasia—A Rare Cause of Difficult Intubation
Authors: Bhagchandani T. , Mohta M. , Sethi A. K. , Tyagi A.
Published: January 2019

Generalized hypoplasia of the larynx and trachea is a very rare condition with only one case reported in the literature. A pregnant woman presented for an emergency laparotomy under general anaesthesia. Endotracheal intubation with conventional sizes of tracheal tubes failed, despite a Cormack and Lehane grade I laryngoscopic view. Subsequent investigations demonstrated generalized hypoplasia of the larynx and trachea. In this report, successful anaesthetic management of this case is discussed along with other possible options.
Effect of Low-Dose Vasopressin Infusion on Vital Organ Blood Flow in the Conscious Normal and Septic Sheep
Authors: Di Giantomasso D. , Morimatsu H. , Bellomo R. , May C. N.
Published: January 2019

The effect of low-dose vasopressin (AVP) on vital regional circulations may be clinically relevant but has not been fully described. We sought to determine the effect of low-dose AVP on systemic haemodynamics, coronary, mesenteric and renal circulations in the conscious normal and septic mammal.

We studied seven Merino sheep using a prospective randomized cross-over double-blind placebo-controlled animal design. We inserted flow probes around aorta, coronary, mesenteric and renal arteries and, three weeks later, we infused low-dose AVP (0.02 IU/min) or placebo in the normal and septic state induced by intravenous E.coli. In normal sheep, AVP (0.02 IU/min) induced a 17% decrease in mesenteric blood flow (393.0±134.9 vs 472.1± 163.8 ml/min, P<0.05) and a 14% decrease in mesenteric conductance (P<0.05). In septic sheep, AVP decreased heart rate and cardiac output by 28% and 22%, respectively (P<0.05). It also decreased mesenteric blood flow and mesenteric conductance by 23% (flow: 468.5±159.7 vs 611.3±136.3 ml/min, P<0.05; conductance: 6.3±2.7 vs 8.2±2.7 ml/min/mmHg; P<0.05). Renal blood flow was unchanged but urine output and creatinine clearance increased (P<0.05). We conclude that low-dose AVP infusion has similar effects in the normal and septic mammalian circulation: bradycardia, decreased cardiac output, decreased mesenteric blood flow and conductance and increased urine output and creatinine clearance. This information is important to clinicians considering its administration in humans.
Electroconvulsive Therapy in Patients with Cardiac Pacemakers
Authors: Macpherson R. D. , Loo C. K. , Barrett N.
Published: January 2019

There are few contraindications to electroconvulsive therapy and it is generally well tolerated. However, electroconvulsive therapy in elderly patients with cardiac pacemakers in situ theoretically presents an increased risk of complications. We undertook a retrospective audit of all patients who received anaesthesia for electroconvulsive therapy between January 1999 and September 2005. There were ten patients who had cardiac pacemakers in situ. They underwent a total of 147 electroconvulsive therapy treatments. In 146 out of the 147 treatments, the anaesthesia proceeded uneventfully. The findings suggest that provision of anaesthesia and electroconvulsive therapy in patients with cardiac pacemakers, including rate-responsive pacemakers, is a safe undertaking, with no extra precautions being needed except for routine ECG monitoring.
The ProSeal™ Laryngeal Mask Airway is an Effective Alternative to Laryngoscope-Guided Tracheal Intubation for Gynaecological Laparoscopy
Authors: Lim Y. , Goel S. , Brimacombe J. R.
Published: January 2019

We tested the hypothesis that the ProSeal™ laryngeal mask airway is superior to laryngoscope-guided tracheal intubation for gynaecological laparoscopy. One-hundred and eighty consecutive patients (ASA grade 1-2, aged 18-80y) were divided into two equal-sized groups for airway management with the ProSeal™ laryngeal mask airway or tracheal tube. Induction was with fentanyl/propofol, maintenance with sevoflurane and muscle relaxation with atracurium. The following primary variables were tested: time to achieve an effective airway, ventilatory capability, peak airway pressure before and after pneumoperitoneum, duration of surgery and pneumoperitoneum and haemodynamic responses. Data about gastric size, airway trauma and sore throat were collected. The number of attempts for successful insertion were similar, but effective airway time was shorter for the ProSeal™ laryngeal mask airway (20±2s vs 37±3s, P<0.001). All devices were successfully inserted within three attempts. There was no episode of failed ventilation or hypoxia. The haemodynamic stress responses to insertion and removal were greater for the tracheal tube than the ProSeal™ laryngeal mask airway. The duration of surgery, duration of pneumoperitoneum and intraabdominal pressures were similar. Gastric size was similar at the start and end of surgery. There were no differences in the frequency of complications or sore throat.

We conclude that the ProSeal™ laryngeal mask airway is a similarly effective airway device to conventional laryngoscope-guided tracheal intubation for gynaecological laparoscopy, but is more rapidly inserted and associated with an attenuated haemodynamic response to insertion and removal.
Resuscitation from Transfusion-Associated Hyperkalaemic Ventricular Fibrillation
Authors: Woodforth I. J.
Published: January 2019

Evidence to guide resuscitation from transfusion-related hyperkalaemic ventricular fibrillation is sparse. This case report describes a 29 kg patient undergoing scoliosis surgery who developed hyperkalaemic ventricular tachycardia/fibrillation following the replacement of over two blood volumes with banked blood in 90 minutes. Rapid reversion to sinus rhythm followed administration of 1.4 mmol of calcium chloride and two units of insulin (Actrapid, Novo Nordisk). The relevant literature is reviewed, indicating that an elevated serum ionised calcium level protects against hyperkalaemia, by an intracellular mechanism. Evidence supports the use of lignocaine, but not amiodarone, as additional treatment.
The Evaluation of Anaesthesia-related Information on the Internet
Authors: Corcoran T. B. , Ward M. , Jarosz K. , Schug S. A.
Published: January 2019

The quality and accessibility of anaesthesia-related information available to patients on the internet is a growing concern for the specialty. We sought to evaluate the quality of anaesthesia-related websites using a simple scoring system.

The scoring system comprised quality and technical scores individually, and these were also combined into a total score. Test-retest reliability was assessed by calculating intraclass correlation coefficients. We employed the four most popular search engines and one meta-search engine, using the search term “general anaesthesia”. Only the first 10 sites retrieved were scored.

The intraclass correlation coefficients for all terms demonstrated at least moderate agreement and the total scores demonstrated high consistency r=0.852, 0.774 (P <0.001, and P <0.003 respectively). There were 18 duplicate websites and 32 were scored. There was no difference between search engines for any of the three scores awarded. The majority of websites were rated as either ‘poor’ or fair’ across all scores.

Our study indicates that quality anaesthesia-related information is unlikely to be retrieved by patients using the internet.
A Survey of Anaesthetists' Perspectives of Communication in the Operating Suite
Authors: Elks K. N. , Riley R. H.
Published: January 2019

We surveyed 222 anaesthetists attending a University of Western Australia conference (n=110) and two public hospitals in Perth (n=112) by anonymous questionnaire in March 2006 regarding communication issues in the operating suite. Forty-one percent (n=92) responded.

Questions concerned communication skills, experiences of good and poor communication and relationship to outcome, attitudes to music and communication courses. Stress in anaesthetists due to poor communication, staff naming practices, information on courses with communication content attended and attitudes to non-verbal communication were also surveyed.

Anaesthetists’ communication skills were self-rated as “very good” by 52% and “average” by 39% of respondents. It was strongly agreed that good verbal communication leads to better patient outcome (57%) and was important between surgeons and anaesthetists (76%). Regarding the current state of surgeon/anaesthetist communication, 25% (23/92) agreed this was acceptable, 33% (30/92) were undecided and 42% (39/92) regarded this as poor. Silence in theatre was generally not desired, 71% preferring background music. Ninety-nine percent of respondents believed good communication decreased stress and 89% felt personally stressed in situations where poor communication occurred. Email/text communication was not preferred to spoken language regarding case information. Sixty-four percent of respondents would attend a communications course voluntarily, with implementation of a compulsory communications course supported by 45%. Most anaesthetists surveyed used staff first names and 94% believed poor communication caused procedural delay.

The data suggest that further work is required to improve communication in the stressful operating room environment, particularly at the surgeon/anaesthetist interface.
Tropisetron plus Subhypnotic Propofol Infusion is more Effective than Tropisetron Alone for the Prevention of Vomiting in Children after Tonsillectomy
Authors: Erdem A. F. , Yoruk O. , Silbir F. , Afici H. A. , Cesur M. , Dogan N. , Aktan B. , Sutbeyaz Y.
Published: January 2019

This study evaluated the efficacy of tropisetron compared with tropisetron and a subhypnotic propofol infusion in preventing postoperative vomiting following tonsillectomy. One hundred and forty healthy children, aged four to 12 years, undergoing tonsillectomy were recruited in a randomised, double-blind study. After induction with sevoflurane, anaesthesia was maintained with sevoflurane and nitrous oxide. All patients received tropisetron (0.2 mg/kg up to 5 mg; intravenously) and fentanyl (2 μg/kg; intravenously) and were intubated after atracurium which was reversed with neostigmine (and atropine). The tropisetron-plus-propofol group received a single dose of propofol (1 mg/kg) before intubation and a continuous infusion of propofol throughout surgery at 15 μg/kg/min. Data for postoperative vomiting were grouped into zero to four and four to 24 hour time intervals. A P value of <0.05 was considered statistically significant.

The percentage of patients exhibiting a complete response (no retching or vomiting for 24 hours) was 47.1% (33/70) in the tropisetron-alone group and 72.8% (51/70) in the tropisetron-plus-propofol group (P=0.002). The 0.257 absolute risk reduction of vomiting with the addition of propofol represents a number needed to treat of 3.87, and a risk ratio of 0.51 (95% CI 0.32 to 0.79). Significantly fewer patients vomited in the tropisetron-plus-propofol group than in the tropisetron-alone group during the zero to four post-surgery interval (P=0.016), but the difference was not statistically significant for the four to 24 hour postoperative period (P=0.116). Intraoperative subhypnotic propofol infusion combined with tropisetron is more effective than tropisetron alone in reducing postoperative vomiting after tonsillectomy in children.
The Ability of Anaesthetists to Identify Generic Medications from Trade Names
Authors: Bramley D. E. P.
Published: January 2019

The recent proliferation of brand names for prescription medications has made the clinician's task of identifying the corresponding generic drug substances more difficult. A survey of 86 anaesthetists and anaesthetic trainees at two Melbourne hospitals was conducted to measure the extent to which this was perceived to be a clinical problem. In addition, a theoretical test was administered to examine the ability of these anaesthetists to correctly identify generic drugs and therapeutic groups when only the brand name is provided. The results indicated this is perceived to be a genuine clinical problem, with more than 80% of respondents encountering unfamiliar trade names ‘often’ or ‘always’ and the test revealing that fewer than one third of commonly prescribed brand names were identified correctly.
Preventing Pain on Injection of Propofol: A Comparison between Peripheral Ketamine Pre-Treatment and Ketamine Added to Propofol
Authors: Hwang J. , Park H.-P. , Lim Y.-J. , Do S.-H. , Lee S. C. , Jeon Y.-T.
Published: January 2019

The purpose of this study was to examine possible peripheral mechanisms for the reduction of propofol injection pain by the addition of ketamine. We hypothesised that pH changes associated with the addition of ketamine to propofol decrease propofol-induced pain on injection. We compared the efficacy of intravenous ketamine pretreatment under tourniquet with ketamine added to the propofol In the pre-treatment group, patients received ketamine 10 mg in a total volume of 1.0 ml with 0.9% saline (n=94; Group P) under tourniquet for 30 seconds before administration of propofol afler release of the tourniquet. In the mixture group, propofol 9 ml was mixed with ketamine 10 mg in 0.9% NaCl 1.0 ml (n=94, Group M). Pain was assessed with a four-point scale: 0=no pain, 1 =mild pain, 2=moderate pain, 3=severe pain at the time of propofol injection. The pH of propofol, ketamine and a range of propofol-ketamine mixtures were also measured. Forty-eight patients (51%) in Group P complained of pain on injection compared with 28 patients (30%) in Group M (P=0.005). The pH of the 1% propofol-ketamine mixture was 5.84 while 1% propofol had a pH of 7.86. Our results support pH changes as a more important cause for the decrease in propofol injection pain with the addition of ketamine to propofol than a peripheral effect of ketamine.
Differential Increases in Blood Flow Velocity in the Middle Cerebral Artery after Tourniquet Deflation during Sevoflurane, Isoflurane or Propofol Anaesthesia
Authors: Kadoi Y. , Kawauchi C. H. , Ide M. , Saito S. , Mizutani A.
Published: January 2019

The purpose of this study was to examine the comparative effects of sevoflurane, isoflurane or propofol on cerebral blood flow velocity after tourniquet deflation during orthopaedic surgery.

Thirty patients undergoing elective orthopaedic surgery were randomly divided into sevoflurane, isoflurane and propofol groups. Anaesthesia was maintained with sevoflurane, isoflurane or propofol infusion in 33% oxygen and 67% nitrous oxide, in whatever concentrations were necessary to keep bispectral index values between 45 and 50. Ventilatory rate or tidal volume was adjusted to target PaCO2 of 35 mmHg. A 2.0 MHz transcranial Doppler probe was attached to the patient's head at the temporal window and mean blood flow velocity in the middle cerebral artery was continuously measured. The extremity was exsanguinated with an Esmarch bandage and the pneumatic tourniquet was inflated to a pressure of 450 mmHg. Arterial blood pressure, heart rate, velocity in the middle cerebral artery and arterial blood gas analysis were measured every minute for 10 minutes after release of the tourniquet in all three groups.

Velocity in the middle cerebral artery in the three groups increased for five minutes after tourniquet deflation. Because of the different cerebrovascular effects of the three agents, the degree of increase in flow velocity in the isoflurane group was greater than in the other two groups, the change in flow velocity in the propofol group being the lowest (at three minutes after deflation 40∓7%, 32∓6% and 28∓10% in the isoflurane, sevoflurane and propofol groups respectively, P <0.05).
Effect of Pre-emptive Alveolar Recruitment Strategy before Pneumoperitoneum on Arterial Oxygenation during Laparoscopic Hysterectomy
Authors: Park H.-P. , Hwang J.-W. , Kim Y. B. , Jeon Y.-T. , Park S.-H. , Yun M. J. , Do S. H.
Published: January 2019

In a randomised, controlled, single-blind trial, we examined the effect of a pre-emptive alveolar recruitment strategy on arterial oxygenation during subsequent pneumoperitoneum. After intubation, 50 patients were randomly allocated to receive either tidal volume 10 ml/kg with no positive end-expiratory pressure (group C) or alveolar recruitment strategy of 10 manual breaths with peak inspiratory pressure of 40 cmH2O plus positive end-expiratory pressure of 15 cmH2O before gas insufflation (group P). During pneumoperitoneum, group P was ventilated with the same setting as group C (FiO2=0.35, tidal volume 10 ml/kg). PaO2 measured during peumoperitoneum was higher in group P than in group C (166∓32 mmHg vs 145∓34 mmHg at 15 minutes, P=0.028, 155∓30 mmHg vs 136∓32 mmHg at 30 minutes, P=0.035). Alveolar-arterial oxygen gradient in group P increased less after gas insufflation (13∓9 to 60∓34 mmHg vs 10∓9 to 37∓31 mmHg, P=0.013). We conclude that the alveolar recruitment strategy we applied before insufflation of the peritoneal cavity may improve oxygenation during laparoscopic hysterectomy.
Application of the Transversus Abdominis Plane Block in the Intensive Care Unit
Authors: Niraj G. , Kelkar A. , Fox A. J.
Published: January 2019

We present three patients admitted to the intensive care unit following major intra-abdominal surgery who underwent ultrasound guided transversus abdominis plane (TAP) block for postoperative analgesia. In two patients, epidural analgesia was relatively contraindicated. In the third patient, the TAP block was used to provide rescue analgesia in the setting of an ineffective epidural. We found that the TAP blocks provided satisfactory analgesia and appeared to enhance recovery by reducing morphine requirements and avoiding opioid-related side-effects. We put forward a case for more frequent use of this simple and safe technique in the intensive care setting.
A Minimum Cost Anaesthesia Machine, Compliant with Australian and New Zealand College of Anaesthetists Professional Document T3, for Medical Missions
Authors: Woodforth I. J.
Published: January 2019

This report describes what seems to be the simplest and least expensive anaesthesia machine possible which complies with the Australian and New Zealand College of Anaesthetists technical document T3.
Regional Anaesthesia for Bilateral Upper Limb Surgery: A Review of Challenges and Solutions
Authors: Holborow J. , Hocking G.
Published: January 2019

Regional anaesthesia for bilateral upper limb surgery can be challenging, yet surgeons are becoming increasingly interested in performing bilateral procedures at the same operation. Anaesthetists have traditionally avoided bilateral brachial plexus block due to concerns about local anaesthetic toxicity, phrenic nerve block and pneumothorax. We discuss these three concerns and review whether advances in ultrasound guidance and nerve catheter techniques should make us reconsider our options. A search of Medline and EMBASE from 1966 to January 2009 was conducted using multiple search terms to identify techniques of providing anaesthesia or analgesia for bilateral upper limb surgery and potential side-effects. Ultrasound imaging and nerve catheter techniques have led to a reduction in dose requirements for effective blocks without side-effects. Effective regional anaesthesia can be performed for bilateral surgery while remaining within recommended safe dose limits. Spacing blocks apart in time can further reduce potential toxicity issues, such that peak absorption rates for each block do not coincide. Since phrenic nerve block remains an issue even with low doses of local anaesthesia, bilateral interscalene blocks are still not recommended. Peripheral nerve blocks have excellent safety profiles and are ideal for ultrasound guidance. Regional anaesthesia can be a suitable option for bilateral upper limb surgery.
The Effect of Transdermal Nitroglycerine on Intrathecal Fentanyl with Bupivacaine for Postoperative Analgesia following Gynaecological Surgery
Authors: Garg A. , Ahmed F. , Khandelwal M. , Chawla V. , Verma A. P.
Published: January 2019

Fentanyl is a short-acting synthetic opioid with spinal analgesic properties and dose-dependent side-effects. The analgesic effect of opioids is mediated in part through activation of inhibitory descending pain pathways involving nitric oxide (as a central neurotransmitter) through the NO-cGMP system. This NO-cGMP pathway plays an important role in spinal nociception. The aim of the study was to evaluate the effect of transdermal nitroglycerine on the analgesic action of intrathecal fentanyl in patients undergoing abdominal hysterectomy. Patients (n=120) were randomised into one of four groups. All received 3 ml bupivacaine 0.5% plus 0.5 ml of an intrathecal test drug. Twenty minutes after lumbar puncture, a transdermal patch of either nitroglycerine or placebo was applied. Group B received spinal bupivacaine plus saline 0.5 ml and a placebo patch. Group B-N received bupivacaine plus saline 0.5 ml and a nitroglycerine patch. Group F received bupivacaine plus fentanyl 25 μg and a placebo patch. Group F-N received bupivacaine plus fentanyl 25 μg and a nitroglycerine patch. The duration of effective analgesia was longer in group FN (363.53±34.09 min) compared from the other groups (P <0.001). The times to two-segment regression in group F-N and group F were 132.87±31.2 min and 126.40±26.81 min respectively. The visual analog scale pain score at the time of the first rescue analgesic was similar in all groups. We conclude that nitroglycerine does not result in postoperative analgesia but enhances the analgesic effect of intrathecal fentanyl.
Assessment of a Cardiac Output Device using Arterial Pulse Waveform Analysis, VigileoTM, in Cardiac Surgery Compared to Pulmonary Arterial Thermodilution
Authors: Hamm J.-B. , Nguyen B.-V. , Kiss G. , Wargnier J.-P. , Jauffroy A. , Helaine L. , Arvieux C. C. , Gueret G.
Published: January 2019

Many devices are available to assess cardiac output (CO) in critically ill patients and in the operating room. Classical CO monitoring via a pulmonary artery catheter involves continuous cardiac output (CCO) measurement. The second generation of Flotrac/VigileoTM monitors propose an analysis of peripheral arterial pulse waves to calculate CO (APCO) without calibration. The aim of our study was to compare the CO between the Swan Ganz catheter and the VigileoTM. In this observational study, nine patients undergoing coronary artery bypass grafting were prospectively included. APCO, mean (CCO) and instantaneous CO (ICO) were measured. Perioperative and postoperative assessments were performed up to 24 hours post-surgery. Measurements were recorded every minute, resulting in the collection of 6492 data pairs. Comparison of APCO and ICO showed a limited bias of -0.1 l/min but an important percentage error of 48%. Corresponding values were -0.1 l/min and 46% for the APCO versus CCO comparison, and 0 and 17% for ICO versus CCO comparison. Large inter-individual variability does exist. During cardiac surgery and after leaving the operating room, VigileoTM is not clinically equivalent to continuous thermodilution by pulmonary artery catheter. Nevertheless, the connection between CCO and ICO relates the difference between APCO and CCO more to the different algorithms used. Further efforts should be concentrated on assessing the ability of this device to track changes in cardiac output.
Excessive Tryptophan Catabolism Along the Kynurenine Pathway Precedes Ongoing Sepsis in Critically Ill Patients
Authors: Zeden J.-P. , Fusch G. , Holtfreter B. , Schefold J. C. , Reinke P. , Domanska G. , Haas J.-P. , Gruendling M. , Westerholt A. , Schuett C.
Published: January 2019

It has recently been shown that an increased plasma level of the tryptophan catabolite kynurenine is an early indicator for the development of sepsis in major trauma patients. We examined the predictive value of kynurenine pathway activity for ongoing sepsis in patients being admitted to a surgical intensive care unit for different reasons. In addition, we asked whether an accumulation of kynurenines in patients’ plasma depends on reduced renal clearance. We conducted a prospective observational study including 100 consecutive patients and monitored laboratory variables, physiological and adverse events, sepsis and outcome. Using tandem mass spectrometry, we quantified the five indoleamines tryptophan, serotonin (5-HT), kynurenine, quinolinic acid and kynurenic acid at baseline and twice a week during the intensive care unit stay. Among the patients enrolled, 50 did not develop sepsis in the intensive care unit (non-septic), 18 patients did not have sepsis at baseline but developed sepsis later on (preseptic) and 32 patients already fulfilled the criteria of severe sepsis and septic shock at baseline (septic). In general, non-septic critically ill patients showed activation of the kynurenine pathway, but septic shock coincided with an exacerbation of kynurenine pathway activity even in the absence of renal failure. Importantly, plasma concentrations of quinolinic acid (area under the curve 0.832 [95% confidence interval 0.710 to 0.954]) and the Quin/Trp ratio (area under the curve 0.835 [95% confidence interval; 0.719 to 0.952]) showed the best discrimination between non-septic and pre-septic patients at baseline. These findings open new avenues for further investigations on the pathophysiology of sepsis.
Pilot Study of the Air-Q Intubating Laryngeal Airway in Clinical Use
Authors: Bakker E.J. , Valkenburg M. , Galvin E. M.
Published: January 2019

The air-Q Intubating Laryngeal Airway (ILA) is a newly introduced extraglottic airway device. In this pilot study, we evaluated its use as a routine airway device during positive pressure ventilation. Ease of endotracheal intubation through the device was also assessed.

Fifty-nine ASA I and II patients undergoing elective surgery received an air-Q ILA and an endotracheal tube where indicated. Insertion, ventilation and intubation characteristics were noted, as well as throat morbidity and occurrence of adverse events.

An air-Q ILA was successfully inserted in 100% of patients. Mean leak pressure was 19±5 cmH2O. Endotracheal intubation was indicated in 19 patients and successful in 58% on the first attempt and 74% in total. Ten percent of the study patients were noted to have dysphagia. One patient was diagnosed with bilateral lingual nerve injury but made a complete recovery in four weeks.

The air-Q ILA is an adequate extraglottic airway device in terms of insertion and ventilation. However, the proposed advantage of ease of endotracheal intubation requires further investigation.
Compartment Syndrome and Patient-Controlled Analgesia in Children – Analgesic Complication or Early Warning System?
Authors: Yang J. , Cooper M. G.
Published: January 2019

We present two cases of children who developed compartment syndrome after upper limb fractures. Morphine patient-controlled analgesia was used in a bolus-only mode for analgesia (bolus 20 μg/kg, five minute lockout and hourly limit of 150 μg/kg). An increase in patient-controlled analgesia use was observed up to 12 hours before the decision was made to proceed to fasciotomy but neither child exceeded the hourly limit or had an excessive increase in pain scores. Clinical risk factors for compartment syndrome should be identified and appropriate monitoring instituted. A subtle increase in patient-controlled analgesia use may be an early indicator of impending compartment syndrome before classical signs such as reporting of pain, pallor, paraesthesiae, paralysis and pulselessness develop. These cases and review of the literature suggest techniques which may assist earlier diagnosis of compartment syndrome include setting a more conservative hourly limit of morphine patient-controlled analgesia such as 80 to 100 μg/kg/hour and graphing of patient-controlled analgesia demands and boluses, pain scores at rest and pain scores with passive flexion and extension of digits. These practices could identify trends that pain or analgesia requirement is increasing leading to earlier diagnosis of compartment syndrome.
Cerebral Flow Pattern Monitoring by Transcranial Doppler during Cardiopulmonary Resuscitation
Authors: Blumenstein J. , Kempfert J. , Walther T. , Van Linden A. , Fassl J. , Borger M. , Mohr F. W.
Published: January 2019

We describe the transcranial Doppler pattern during a period of cardiopulmonary resuscitation in a patient undergoing a transcatheter off-pump aortic valve implantation. Transcranial Doppler of the middle cerebral artery flow was measured as a part of a separate ongoing study. The patient developed a cardiac arrest during deployment of the valve prosthesis. The incidental presence of the transcranial Doppler allowed us to assess middle cerebral artery flow during cardiopulmonary resuscitation in real time. An initial lack of a diastolic flow pattern seen with transcranial Doppler at the beginning of cardiopulmonary resuscitation led to volume loading and optimisation of the resuscitation technique. After increasing the depth of external cardiac massage, the cerebral flow pattern improved to produce sufficient diastolic flow. The transcranial Doppler provided additional information during cardiopulmonary resuscitation, which was helpful in clinical management. The use of transcranial Doppler may be helpful for other cardiac procedures where cerebral malperfusion may occur.
Plasmapheresis Treatment in Guillain-Barré Syndrome: Potential Benefit over Intravenous Immunoglobulin
Authors: Buzzigoli S. B. , Genovesi M. , Lambelet P. , Logi C. , Raffaelli S. , Cattano D.
Published: January 2019

Guillain-Barré syndrome includes acute inflammatory demyelinating polyradiculoneuropathy, acute motor axonal neuropathy, acute motor and sensory axonal neuropathy, Miller Fisher syndrome and acute pandysautonomia. Plasma exchange was the first treatment in Guillain-Barré syndrome proven to be superior to supportive treatment alone and intravenous immunoglobulin was subsequently shown to be equally effective and is now commonly used as first-line treatment. We describe a 78-year-old woman who presented with a two-day history of progressive generalised weakness and left facial nerve palsy, preceded by a flu-like illness lasting for one week. A five-day course of daily immunoglobulin (0.4 g/kg/day) was commenced without benefit and progressive clinical deterioration. Seven days after completion of immunoglobulin treatment, plasma exchange was started with an exchange of about three litres of plasma every day for three days and every second day on two further occasions. A gradual improvement of respiratory function and peripheral muscle strength was observed after the first plasma exchange and on the eighth day the patient was weaned off mechanical ventilation. This case suggests that patients with severe Guillain-Barré syndrome may benefit from plasma exchange after immunoglobulin treatment in refractory cases. Plasma exchange should be considered early in Guillain-Barré syndrome cases with axonal involvement, and in the recurrent or familial Guillain-Barré syndrome forms.
Successful use of Rocuronium and Sugammadex in an Anticipated Difficult Airway Scenario
Authors: McTernan C. N. , Rapeport D. A. , Ledowski T.
Published: January 2019

Neuromuscular blocking agents are often avoided in anticipated difficult airway scenarios. However, to facilitate jet ventilation, muscle relaxants are useful. We report a case of a potentially threatened airway in a 21-year-old with a large infraglottic pedunculated polyp. In this case rocuronium was used on induction to facilitate subsequent jet ventilation and periglottic laser ablation of the tumour. As the duration of the surgery was not predictable, the intention was to use sugammadex at the end to ensure complete reversal of muscle relaxation. This strategy also provided a quick rescue option if there was a sudden loss of the airway.