bluuebunny/crossref_metadata_2025 huggingface dataset:
Does Left Ventricular Tissue Doppler Peak Systolic Velocity (Sm) Reflect Cardiac Output in the Critically Ill?
Authors: Golowenko A. R. , Nalos M. , Huang S. J.
Published: January 2019

Cardiac output (CO) is dependent on a number of factors, in particular, the systolic function of the heart. Tissue Doppler (TD) is a modality in echocardiography that measures myocardial velocity and is related to contractility. TD can therefore be used to measure the systolic function of the heart. This study sought to establish whether the systolic component of TD can be used to estimate CO in critically ill patients.

Retrospective data was obtained from a total of 80 patients: 29 patients with a normal echocardiogram, and 51 intensive care unit patients; 28 septic and 23 with heart failure.

The mean TD peak systolic velocity (Sm) was significantly lower in the heart failure patients ( P <0.05) compared to both normal and septic group. The mean CO was significantly higher in septic patients when compared to heart failure patients. A mild to moderate positive correlation was found between Sm and CO in the heart failure group and with all patients combined (r2=0.19, P <0.001). Subsequent analysis of Sm versus stroke volume again showed a mild positive correlation in the heart failure group and combined results (r2=0.18, P <0.001). Sm was weakly correlated to heart rate only in the normal group but not in the combined cohort.

Our data confirms a weak to moderate correlation between Sm and CO, probably resulting from a positive correlation of Sm and stroke volume. This correlation is not strong enough to support the use of an individual's Sm to estimate CO in intensive care patients.
Effect of Alkalinisation of Lignocaine for Propofol Injection Pain: A Prospective, Randomised, Double-Blind Study
Authors: Ozgul U. , Begeç Z. , Erdogan M. A. , Aydogan M. S. , Sanli M. , Çolak C. , Durmus M.
Published: January 2019

The aim of this study was to determine whether pretreatment with alkalinised lignocaine reduced the incidence and severity of pain during propofol injection. This prospective, randomised, double-blind study included 300 adult, American Society of Anesthesiologists physcial status I to II patients undergoing elective surgery. Patients were randomly allocated to one of three groups: Group L received 0.05 ml/kg of 1% lignocaine (5 ml normal saline + 5 ml 2% lignocaine), Group A received 0.05 ml/kg alkalinised lignocaine (5 ml 2% lignocaine + 1 ml 8.4% NaHCO3 + 4 ml normal saline), and Group S, the control group, was given the same amount of normal saline (NaCl 0.9%). All drugs were given as a bolus over 20 seconds before propofol administration. A blinded researcher assessed the patient's pain level using a four-point scale. The pain score [median (range)] and the incidence of pain in Group A (6%) was significantly lower than in groups L (41%) and S (88%, P <0.001). In addition, the pain score and the incidence of pain were found to be significantly different between Group L and Group S ( P < 0.001). The incidence of moderate and severe pain were greater in Group S when compared with groups A and L (P <0.001). Intravenous pretreatment with alkalinised lignocaine appears to be effective in reducing the pain during propofol injection.
Current Oxygenation Practice in Ventilated Patients—An Observational Cohort Study
Authors: Panwar R. , Capellier G. , Schmutz N. , Davies A. , Cooper D. J. , Bailey M. , Baguley D. , Pilcher D. V. , Bellomo R.
Published: January 2019

Oxygen therapy is a mainstay of critical care medicine, yet its optimal therapeutic use has not been systematically evaluated. A detailed understanding of current practice in oxygen therapy in intensive care is required to enable future interventional studies. We aimed to describe current oxygenation practice in patients requiring >48 hours of mechanical ventilation (MV) at an academic tertiary referral centre.

We collected longitudinal arterial blood gas and hourly oxygenation data from intensive care unit charts in a consecutive cohort of 40 trauma, 41 medical and 20 surgical patients for their first seven MV days, analysed data for 14,063 MV hours, and derived time-weighted averages (TWA) of variables for each 24-hour interval on MV for all patients.

The TWA-FiO2 was 0.42 (95% CI 0.41 to 0.44) and TWA-SpO2 was 97.1% (95% CI 96.8 to 97.4) for the first seven MV days. TWA-PaO2 was >80 mmHg on 80% of MV days. TWA-FiO2 of ≥0.35 was used to achieve TWA-SpO2 >95% on 61% of MV days. Of 58 MV days with TWA-FiO2 ≥0.60, TWA-SpO2 ≥96% occurred on 28 (48%) days. Mean SpO2 and PaO2 in patients with severe acute lung injury (ATI) scores were higher than recommended targets. Wide variability in the mean SpO2 and PaO2 was observed in patients with comparable ATI scores.

Inspired oxygen therapy in these MV patients was ‘liberal’, with PaO2 and SpO2 values generally above 80 mmHg and 96% respectively. An interventional study comparing current practice to more conservative targets (PaO2≍60 to 65 mmHg and/or SpO2≍90 to 92%) appears possible.
Critical Airway Obstruction by Mediastinal Masses in the Intensive Care Unit
Authors: Hsu A. A. L.
Published: January 2019

Critical airway obstruction is a dreaded complication of a mediastinal mass. The acute management is difficult and catastrophic outcomes have been reported. A total of 19 patients, aged between 13 and 69 years, who had critical major airway obstruction due to mediastinal mass requiring mechanical ventilation were reviewed. Three patients had benign pathologies (retrosternal goitre, bronchogenic cyst, giant left atrium) and three had lymphoma. The remaining patients had advanced malignancies: metastatic mediastinal lymphadenopathy (n=6), thyroid carcinoma (n=1) and oesophageal carcinoma (n=6). Three patients underwent surgery, three received chemotherapy and 15 had airway stenting under deep intravenous sedation. Apart from one patient who had brain haemorrhage and nosocomial infection after cardiac surgery, all other patients were successfully weaned off ventilation within five days after the interventions to alleviate the major airway obstruction without major complications. All patients were discharged from hospital without supplemental oxygen. Patients who had benign pathologies and lymphoma (n=6, 32%) were still alive after a mean follow-up period of six years (range 3 to 10) and those with metastatic disease died after a mean survival period of 3.3 months (range 1 to 9). In summary, critical major airway obstruction is caused by a heterogeneous group of mediastinal pathologies, and the definitive treatment and long-term prognosis of these patients are highly dependent on the underlying aetiology. Combining various therapeutic modalities can lead to successful separation of these patients from mechanical ventilation within a short period of time.
Binding of Local Anaesthetics to the Lipid Emulsion Clinoleic™ 20%
Authors: Evans J. A. , Wallis S. C. , Dulhunty J. M. , Pang G.
Published: January 2019

Lipid emulsions have been used to treat cardiovascular collapse due to local anaesthetic toxicity. However, there are few data available on the comparative efficiency of the partitioning properties of available lipid emulsions in clinical use. This in vitro study compared the buffering properties of the lipid emulsions Clinoleic™ 20% (Baxter, Old Toongabbie, NSW) and Intralipid® 20% (Fresenius Kabi, Pymble, NSW) using both bupivacaine (Marcain® 0.5%, AstraZeneca, North Ryde, NSW) and ropivacaine (Naropin® 1%, AstraZeneca, North Ryde, NSW). The concentration of anaesthetic in buffer before and after mixing with lipid was quantified using chromatographic analysis. Bupivacaine was more effectively bound by the lipid agents, with a 40% reduction in initial concentration. Ropivacaine demonstrated a 20% reduction in concentration with the addition of lipid agents. Importantly, there was no significant difference between Intralipid and Clinoleic in terms of their buffering behaviour, suggesting equivalent binding efficacy.
Pioneering Paediatric Intensive Care Medicine in New Zealand
Authors: Trubuhovich R. V.
Published: January 2019

The origin of New Zealand's paediatric intensive care medicine lay in the formal establishment of Auckland Hospital's Central Respiratory Unit within the hospital's Infectious Diseases Unit (December 1958). It was initially established for the care of critically ill children, chiefly with airway and respiratory disorders or tetanus. Senior Specialist Anaesthetist Matthew Spence soon took charge, his first annual report (1960) briefly describing six children among 19 admissions and another six consulted on elsewhere. Rapid build-up of paediatric admissions—36 in 1963 becoming 104 in 1969—is detailed through Dr Spence's admirable annual reports for that period, which also provide the evidence of his organisational brilliance and personal commitment to development of the unit. Treatment for children, approximately a third of all admissions, soon included management of brain swelling from meningitis, intractable convulsions, traumatic brain injury, etc. Critically ill children were occasionally flown into Auckland; others were cared for regionally as further intensive care units developed throughout New Zealand. Successive additions to medical staffing gradually resulted in four full-time intensivists after Dr Spence's retirement in 1983. Dr James Judson computerised record-keeping from 1984 and developed a large database, containing details of children with numbers approaching 2000. At the end of 1991, the (now) Department of Critical Care Medicine completed its paediatric role over three decades, with care of children passing to a paediatric intensive care unit in the new Auckland paediatric hospital (soon to be called “Starship”). Regional intensive care units still make a substantial contribution to paediatric intensive care countrywide.
Nerve Sheath Catheter Analgesia for Forequarter Amputation in Paediatric Oncology Patients
Authors: Kaddoum R. N. , Burgoyne L. L. , Pereiras L. A. , Germain M. , Neel M. , Anghelescu D. L.
Published: January 2019

In a single centre over two years, four children (7 to 10 years old) with upper limb osteosarcoma underwent chemotherapy followed by forequarter amputation. All patients had preoperative pain and were treated with gabapentin. Nerve sheath catheters were placed in the brachial plexus intraoperatively and left in situ for five to 14 days. After surgery, all patients received local anaesthetic infused via nerve sheath catheters as part of a multimodal analgesia technique. Three of the four patients were successfully treated as outpatients with the nerve sheath catheters in situ. All four children experienced phantom limb pain; however, it did not persist beyond four weeks in any patient.
Arthur Guedel's Laryngeal Plug
Authors: Haridas R. P. , Nichols T. T.
Published: January 2019

The laryngeal plug is a little-known device developed by Arthur E. Guedel in the 1930s. The device was an alternative to the inflatable cuff used on tracheal tubes. Guedel did not publish a description of the laryngeal plug and the most detailed description of it was published by Gilbert Troup, an Australian anaesthetist.
Overview of the Introduction of Neuromuscular Monitoring to Clinical Anaesthesia
Authors: Loughnan T. E. , Loughnan A. J.
Published: January 2019

Muscle relaxants were introduced into clinical practice in the early 1940s. From 1949, assessments were being made of the efficacy of various agents in awake volunteers, usually the researchers themselves. From the early to mid 1950s, while interest in using muscle relaxants was keen, concern emerged in the surgical literature that there was a higher mortality rate seen in patients receiving muscle relaxants. In fairness, the major article highlighted lack of randomisation, bias and confounding variables but this was largely regarded as showing a toxicity associated with muscle relaxants. By 1961 the matter had been settled that muscle relaxants were not toxic but required careful management and administration. Perhaps fortuitously, measurement of the degree of muscle relaxation was introduced to clinical practice with the use of nerve stimulation. These were measured responses to single twitch stimulus or tetanic stimulation. In 1970, train-of-four ratio was introduced, then in 1981 post-tetanic count, and in 1989 double burst stimulation. This article reviews the introduction of these techniques.
A Randomised Controlled Trial of Parecoxib, Celecoxib and Paracetamol as Adjuncts to Patient-Controlled Epidural Analgesia after Caesarean Delivery
Authors: Paech M. J. , Mcdonnell N. J. , Sinha A. , Baber C. , Nathan E. A.
Published: January 2019

The benefit of combining non-opioid analgesics with neuraxial opioids for analgesia after caesarean delivery has not been clearly established. Larger doses of paracetamol or cyclooxygenase-2 inhibitors have not been evaluated. A randomised, double blind, double-dummy, parallel group placebo-controlled clinical trial was conducted among women having elective caesarean delivery under spinal anaesthesia, followed by pethidine patient-controlled epidural analgesia. Patients received placebos (group C); intravenous parecoxib 40 mg then oral celecoxib 400 mg at 12 hours (group PC); intravenous paracetamol 2 g then oral 1 g six-hourly (group PA); or these regimens combined (group PCPA). The primary outcome was 24-hour postoperative patient-controlled epidural pethidine use and the main secondary outcome was postoperative pain. One hundred and thirty-eight women were recruited but 27 subsequently met exclusion criteria, leaving 111 who were randomised, allocated and analysed by intention-to-treat (n=23, 30, 32 and 26 in groups C, PC, PA and PCPA respectively). There were no differences between groups for pethidine consumption, based on either intention-to-treat (median 365, 365, 405 and 360 mg in groups C, PC, PA and PCPA respectively, P=0.84) or per protocol analysis (17 major violations). Dynamic pain scores did not differ between groups but requirement for, and dose of, supplementary oral tramadol was least in group PCPA (incidence 23% versus 48%, 70% and 58% in groups C, PC and PA respectively, P=0.004). The addition of regular paracetamol, cyclooxygenase-2 inhibitors or both to pethidine patient-controlled epidural post-caesarean analgesia did not provide a pethidine dose-sparing effect during the first 24 hours.
Observational Study of Dexmedetomidine for Hysteroscopy, Cystoscopy and Transrectal Ultrasound Biopsy
Authors: Keane M. J. , Manikappa S. , Alrawi N. N. S.
Published: January 2019

Dexmedetomidine shows promise of being an airway-stable drug. It is approved in Australia for procedural sedation. However, it is important to note that in the study on which this indication is based, all the subjects received a local anaesthetic block before their procedure or surgery. In this regard, as Health Canada has explicitly stated, further evidence still needs to be gained for the use of dexmedetomidine for procedural sedation without accompanying nerve blocks. The purpose of this current proof-of-concept, observational study is to provide further information about dexmedetomidine in three regards. First, can dexmedetomidine be used for procedural sedation per se (i.e. without local anaesthetic blocks)? Second, as opposed to results being averaged out over a wide variety of procedures, the current study examined the feasibility of dexmedetomidine-based procedural sedation for three specific procedures. Third, the current study aims to add to the pool of information regarding the appropriate dose of dexmedetomidine. As described in the dexmedetomidine product information, the Observer's Assessment of Alertness/Sedation Scale grades sedation from 5 (alert) down to 1 (deepest level of sedation). In the study on which dexmedetomidine's indication for procedural sedation is based, patients needed only to achieve a score of 4 and, thus, the approved product information recommends a loading dose of 1.0 μg/kg followed by a maintenance infusion of 0.2 to 1.0 μg/kg/hour. This current study aims to add to the literature regarding the safety of dexmedetomidine when used at higher than recommended doses.
A Ten-Year Audit of Fresh Gas Flows in a New Zealand Hospital: The Influence of the Introduction of Automated Agent Delivery and Comparisons with Other Hospitals
Authors: Kennedy R. R. , French R. A.
Published: January 2019

Reducing fresh gas flow (FGF) rates with volatile anaesthetics reduces waste, with positive financial and environmental consequences. We have audited FGF since 2001 by analysis of data collected from anaesthetic machines. We recently introduced Aisys® (GE Healthcare, Madison, WI, USA) machines that allow automated control of end-tidal levels of volatile anaesthetics. In 2009 the mean FGF was 1.27 1/minute, which was lower than 2001 (2.05 1/minute) and 2006 (1.43 1/minute) and similar to two other New Zealand hospitals. Following introduction of the Aisys®, mean FGF initially increased to 1.5 1/minute, but fell to 1.09 1/minute over the following 12 months. Median FGF showed a similar pattern and is now <600 ml/minute. Since introduction of the Aisys® workstation the proportion of time with flow rates >41/minute has increased. The proportion of time spent in automated delivery mode has increased from 35% to 63%. Users valued the workload reduction with end-tidal control. Our findings suggest that in daily practice, with a wide range of practitioners at different levels of training and a broad patient mix, mean flow rates of around 1.3 1/minute with median flows in the range 0.5 to 1.0 1/minute are achievable targets.
Time to Get Comfortable with a Labour Epidural
Authors: Barker H. M. , Simmons S. W. , Hiscock R. J. , Cyna A. M. , Mcdonald S.
Published: January 2019

Women frequently request regional analgesia during labour, yet little is known about how long it takes before they become comfortable. This prospective observational study aimed to determine various time-points following maternal request for regional analgesia in labour until comfort was achieved. It was conducted in two tertiary referral centres for maternity care in Australia between December 2009 and May 2010. Midwives and anaesthetists recorded times of maternal request for regional analgesia, anaesthetist contact, anaesthetist's arrival in the labour room, local anaesthetic infiltration on starting the procedure, injection of neuraxial local anaesthetic and first report of maternal comfort. Composite median times and interquartile range were recorded for maternal request to anaesthetist arrival, anaesthetist arrival to maternal comfort and total time from request to comfort. Statistical modelling and regression analyses assessed possible factors associated with these time intervals. A P value <0.05 was considered significant. Of the 324 maternal requests, 244 out of 324 (75.3%, 95% confidence interval 70.2% to 79.9%) were recorded as having achieved satisfactory labour analgesia. Median interquartile range times observed were: maternal request to anaesthetist arrival: 20 (10 to 35) minutes; anaesthetist arrival to maternal comfort: 40 (30 to 50) minutes; and total time from request to comfort: 65 (50 to 85) minutes. We have shown that approximately one hour is required for a mother to achieve comfort following her request for epidural analgesia during labour. Our findings are likely to provide useful information for antenatal education, enhance informed consent and improve the provision of anaesthetic services for labour analgesia.
Loss of Chance in Medical Negligence
Authors: Leslie K. , Bramley D. , Shulman M. , Kennedy E.
Published: January 2019

Occasionally accidents and complications occur during anaesthesia and perioperative care that result in injury to the patient. Unfortunately, this is sometimes due to a breach in the anaesthetist's duty of care to the patient. Sometimes, rather than being the cause of immediate damage, the act or omission results in an alteration in the prognosis of the complaint or increased risk of complications related to the complaint. This avenue for a negligence action is known as ‘loss of chance of a better outcome’ and has been the subject of much legal argument in Australia in recent years. A recent High Court of Australia decision is widely seen as having ‘closed the door’ to, or at least made it difficult for the patient to succeed in, loss of chance cases. Many anaesthetists may not be familiar with the concept of ‘loss of chance’. This review will explore the concept of loss of chance and the manner in which Australian courts have dealt with it before and after Tabet v Gett from the perspective of the anaesthetist.
Monitoring Temperature in Children Undergoing Anaesthesia: A Comparison of Methods
Authors: Drake-Brockman T. F. E. , Hegarty M. , Chambers N. A. , Von Ungern-Sternberg B. S.
Published: January 2019

Children undergoing anaesthesia are prone to hypothermia. Perioperative monitoring of patient temperature is, therefore, standard practice. Postoperative temperature is regarded as a key anaesthetic performance indicator in Australian hospitals. Many different methods and sites of temperature measurement are used perioperatively. It is unclear to what degree these methods might be interchangeable. The aim of this study was to determine the relationships between temperatures measured at different sites in anaesthetised children. Two hundred children, 0 to 17 years, undergoing general anaesthesia for elective non-cardiac surgery, were prospectively recruited. Temperature measurements were taken in the operating theatre concurrently at the nasopharynx, tympanic membranes, temporal artery, axilla and skin (chest). Patient age and weight were documented. Temperatures varied according to site of measurement. The mean difference from nasopharyngeal temperature to temperatures at left and right tympanic, temporal, axillary and cutaneous sites were +0.24°C, +0.24°C, +0.35°C, −0.38°C and −1.70°C, respectively. Levels of agreement to nasopharyngeal temperature were similar at tympanic, temporal and axillary sites. Tympanic and temporal temperatures were superior to axillary temperatures for detection of mild hypothermia (<36°C). Skin temperature showed a large variation from nasopharyngeal measurements. Our findings indicate that measured temperatures vary between sites. Understanding these variations is important for interpreting temperature readings.
Effect of Statins on Insulin Requirements during Non-Cardiac Surgery
Authors: Turan A. , Egan C. , You J. , Sessler D. , Abdelmalak B.
Published: January 2019

Statins are thought to potentially impair glucose metabolism, increasing plasma glucose concentration. The effect of prolonged statin use on glucose metabolism among outpatients is thus well established. However, the impact of statin use on glucose concentrations and insulin requirements during surgery remains poorly characterised and may very well differ considering the substantial hyperglycaemic stress response to surgery. We conducted a study to test the hypothesis that patients taking statins preoperatively require more intraoperative insulin than non-users. We analysed 173 adults having major non-cardiac surgery who participated in the Dexamethasone, Light Anaesthesia and Tight Glucose Control Trial between 2007 and 2010. We compared statin and non-statin users on total amount of intraoperative insulin to maintain plasma glucose concentration within 4.4 to 6.1 mmol/l using the inverse propensity score weighting method. Sixty-seven patients were statin users and 106 were non-statin users. The estimated ratio of geometric means between the statin users and the non-users was 1.45 (95% confidence interval: 0.93, 2.26, statin versus non-statin, P=0.11). The total amount of intraoperative insulin usage did not differ significantly among patients taking different types of statins ( P=0.50). While the total amount of intraoperative insulin used was not statistically different between the statin users and non-users, we observed a potentially important trend toward insulin resistance intraoperatively among statin users during major non-cardiac surgery. This result is consistent with non-operative settings and cardiac surgery. Further investigation is essential to determine whether this effect is real and, if so, determine which specific statins are more associated with insulin resistance.
The Effect of Patient Sex on the Incidence of Early Adverse Events in a Population of Elderly Patients
Authors: Conti D. , Ballo P. , Boccalini R. , Boccherini A. , Cantini S. , Venni A. , Pezzati S. , Gori S. , Franconi F. , Zuppiroli A. , Pedullà A.
Published: January 2019

Patient sex is known to influence the response to general and regional anaesthesia and recovery after surgery. However, most studies come from analyses carried out on middle-aged patients. As most of the patients admitted to the post-anaesthesia recovery room in our institution are elderly, we took the opportunity to investigate the association between sex and incidence of early adverse events in this older population of patients after major surgery. Consecutive patients undergoing general, orthopaedic, urological and gynaecological surgery, admitted to the recovery room of our institution over a 15-month period, were retrospectively studied. The following adverse events were considered in the analysis: shivering, postoperative nausea and vomiting, hypotension and hypertensive responses, new arrhythmias requiring treatment, acute respiratory failure and desaturation. A total of 1347 patients (mean age 73.3±15.1 years, 61.4% women) were included. Women showed a higher incidence of shivering (relative difference +48%, P=0.0003), postoperative nausea and vomiting (+91%, P<0.0001), hypotension (+32%, P=0.044) and desaturation (+60%, P=0.0030) than men. The incidence of hypertensive response, arrhythmias and acute respiratory failure were not statistically significantly different. The findings of this exploratory study suggest that women have a higher risk of early postoperative adverse events even in a more elderly population.
Accuracy and Reliability of the i-STAT Point-of-Care Device for the Determination of Haemoglobin Concentration before and after Major Blood Loss
Authors: Ng W. L. , Short T. G. , Gunn K. N. , Fuge G. S. , Slon B.
Published: January 2019

We investigated the accuracy of i-STAT® (Abbott Point of Care Inc., Princeton, NJ, USA) haemoglobin (Hb) measurement in surgical patients with an estimated blood loss of ≥25% of total blood volume. Blood tests for i-STAT® Hb, laboratory Hb (Sysmex XE-2100™, Sysmex Corporation, Kobe, Japan) and total plasma proteins were obtained at the start of surgery (T=0) and when an estimated 25% total blood volume loss had occurred (T=1). Thirty-one patients were recruited. The coefficient of variation of the paired i-STAT Hb estimates was 2.8% and 2.9% at T=0 and T=1, respectively. The mean difference between i-STAT® and laboratory Hb was −7.6 g/l (standard deviation 6.5) at T=0 and −5.1 g/l (standard deviation 12) at T=1. The mean total plasma protein difference (total plasma protein T=0 minus T=1) was 13.6 g/l (95% confidence interval 10.2 to 17.0). There was poor correlation between total plasma protein and bias in i-STAT® measurements. The i-STAT® Hb had an acceptable coefficient of variation, but the Hb levels were lower than those estimated by the laboratory. The standard deviation of i-STAT® Hb was greater after ≥25% estimated total blood volume loss. Clinicians should not use the i-STAT® Hb in isolation for clinical decision-making when considering blood transfusion in a situation of 25% or greater blood loss.
The Medical Officer's Journal: HMAS Sydney, 1913 to 1922. An Australian Naval Record of Surgery and Anaesthesia at the Time of the Outbreak of World War I
Authors: Mcdonald J. M. , Todd E. M.
Published: January 2019

The Medical Officer's Journal of HMAS Sydney was a record kept by the ship's surgeon, Leonard Darby, of the conditions on the ship and the health, diseases, injuries and treatment of the sailors under his care. Records of anaesthesia and surgery indicate chloroform was mostly administered, as was ether occasionally. There was some use of intravenous and subcutaneous fluids for resuscitation. The journal also provides an eyewitness account of the Sydney– Emden battle on 9 November 1914 which occurred off the Cocos (Keeling) Islands and was a famous first victory for the young Australian Navy, making headlines around the world. The treatment of the many injured, mostly Germans, is described with the two Australian surgeons and the surviving German surgeon working together.
ANZAC Doctors at Gallipoli and their Contributions to Anaesthesia in Australia
Authors: Cooper M. G. , Morris G.
Published: January 2019

This year marks the centenary of the start of World War I and, with the coming centenary of the involvement of the Australian and New Zealand Army Corps in the Gallipoli campaign in April 2015, we look at the careers of four doctors who served at Gallipoli and their various contributions to anaesthesia. Drs Eric W. B. Woods, John W. B. Bean, Piero F. B. Fiaschi and Bernard T. Zwar all served as part of the Australian Army Medical Corps. All survived the war.
Spinal Anaesthesia with Adjunctive Intrathecal Morphine versus Continuous Lumbar Plexus Blockade: A Randomised Comparison for Analgesia after Hip Replacement
Authors: Fredrickson M. J. , Danesh-Clough T. K.
Published: January 2019

Following elective total hip replacement, both continuous lumbar plexus blockade and spinal anaesthesia (with adjunctive intrathecal morphine) have shown early outcome benefits over opioid analgesia and single-injection nerve block. However, the two techniques have not been compared in a prospective randomised manner. Our study examined 50 patients undergoing elective hip joint replacement who were randomised to receive spinal anaesthesia (with adjunctive intrathecal morphine 0.1 mg) or patient-controlled continuous lumbar plexus blockade. All surgery was conducted under general anaesthesia. Measured outcomes included numerically rated postoperative pain, supplemental opioid consumption and indices of mobilisation together with complications. Results show that block placement time was marginally shorter for the spinal group (5 versus 7 minutes, P=0.01). The primary outcome, worst pain on movement/mobilisation during the first 24 hours, was not statistically significantly different between groups. Patients in the lumbar plexus group were given more intraoperative opioid and rescue morphine in the post-anaesthesia care unit (median = 4 versus 0 mg, P <0.001), with correspondingly higher pain scores (median 5/10 versus 0/10, P <0.001). Pain scores during the subsequent 24 hours were similar between groups, but more patients in the spinal group were given rescue morphine (5 versus 0, P=0.02). Physiotherapy mobilisation indices appeared similar between groups. More spinal group patients reported pruritus (12 versus 5, P=0.01), but antiemetic requirements, episodes of disorientation, arterial oxygen desaturation and falls were all similar between groups. Postoperative symptoms suggestive of neurological irritation or injury did not differ between groups. We found that following elective hip joint replacement, compared to continuous lumbar plexus blockade, spinal anaesthesia incorporating adjunctive intrathecal morphine did not result in a statistically significant difference in worst pain on movement/mobilisation during the first 24 hours, although it was associated with better analgesia in the post-anaesthesia care unit. Subsequently, however, these patients appeared to require more rescue morphine and more of them reported pruritus.
Surgical Site Infection—A Population-Based Study in Australian Adults Measuring the Compliance with and Correct Timing of Appropriate Antibiotic Prophylaxis
Authors: Hooper T. D. , Hibbert P. D. , Hannaford N. A. , Jackson N. , Hindmarsh D. M. , Gordon D. L. , Coiera E. C. , Runciman W. B.
Published: January 2019

Prophylaxis for surgical site infection (SSI) is often at variance with guidelines, despite the prevalence of SSI and its associated cost, morbidity, and mortality. The CareTrack Australia study, undertaken by a number of the authors, demonstrated that appropriate care (in line with evidence- or consensus-based guidelines) was provided at 38% of eligible SSI healthcare encounters. Here, we report the indicator-level CareTrack Australia findings for SSI prophylaxis. Indicators were extracted from Australian and international clinical guidelines and ratified by clinical experts. A sample designed to be representative of the Australian population was recruited (n=1154). Participants’ medical records were reviewed and analysed for compliance with the five SSI indicators. The main outcome measure was the percentage of eligible healthcare encounters with documented compliance with indicators for appropriate SSI prophylaxis. Of the 35,145 CareTrack Australia encounters, 702 (2%) were eligible for scoring against the SSI indicators. Where antibiotics were recommended, compliance was 49% for contaminated surgery, 57% for clean-contaminated surgery and 85% for surgery involving a prosthesis: these fell to 8%, 10% and 14%, respectively (an average of 11%), when currently recommended timing of antibiotic administration was included. Where antibiotics were not indicated, 72% of patients still received them. SSI prophylaxis in our sample was poor; over two-thirds of patients were given antibiotics, whether indicated or not, mainly at the wrong time. There is a need for national agreement on clinical standards, indicators and tools to guide, document and monitor SSI prophylaxis, with both local and national measures to increase and monitor their uptake.
Randomised Controlled trial Comparing the Ambu® aScope™2 with a Conventional Fibreoptic Bronchoscope in Orotracheal Intubation of Anaesthetised Adult Patients
Authors: Chan J. K. , Ng I. , Ang J. P. , Koh S. M. , Lee K. , Mezzavia P. , Morris J. , Loh F. , Segal R.
Published: January 2019

Fibreoptic intubation remains an essential skill for anaesthetists to master. In addition to the reusable fibrescope, an alternative disposable videoscope is available (aScope™2, Ambu®, Ballerup, Denmark). A total of 60 anaesthetised adult patients were randomised to either having orotracheal intubation using the aScope 2 or a Karl Storz fibrescope. Intubations were performed by experienced operators who were familiar with both devices. The primary outcome was the Global Rating Scale score. Secondary outcomes included intubation success, number of intubation attempts and intubation time. Other subjective outcomes including practicality, useability and image quality were also recorded. There was no significant difference in the Global Rating Scale score, intubation success or intubation time between the aScope 2 or Karl Storz fibrescope. Global Rating Scale scores were three and two in the aScope 2 and Karl Storz groups respectively ( P=0.14). All of the other subjective outcomes were similar between the two groups, except that operators found it easier to use the aScope 2 compared to the fibrescope. There was no significant difference in clinical performance between the aScope 2 and the Karl Storz fibreoptic bronchoscope. The aScope's practicality, disposability and recently improved version (aScope™3) potentially make it an acceptable alternative to the reusable fibrescope.
Does Adding ICU Data to the POSSUM Score Improve the Prediction of Outcomes following Surgery for Upper Gastrointestinal Malignancies?
Authors: Butterfield R. , Stedman W. , Herod R. , Aneman A.
Published: January 2019

Surgery for upper gastrointestinal malignancy carries a high postoperative mortality and morbidity risk. The importance of preoperative physiological reserve and intraoperative events in determining clinical outcomes is recognised in the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) score that comprises variables relevant to both phases. Whether adding variables linked to ICU admission characteristics improves the predictive capacity of POSSUM is unclear, especially in an Australian/New Zealand healthcare context. This study aimed to evaluate the predictive capacity of the POSSUM score for 30-day mortality and in-hospital morbidity in 80 patients undergoing resection of oesophageal (28%), gastric (26%) or pancreatic (46%) malignancies and admitted to ICU. The 30-day mortality was 8.8% and 65% of patients developed some postoperative complication. Receiver operating characteristics generated an area under the curve (95% CI) to predict mortality by Portsmouth POSSUM of 0.87 (0.77 to 0.93) and morbidity by POSSUM of 0.67 (0.55 to 0.77). Multiple regression analysis including biochemical variables and vital signs on admission to ICU identified renal function parameters, fluid balance and need for cardiorespiratory support beyond the first postoperative day as independent factors associated with mortality and morbidity (in addition to the POSSUM score) but the inclusion of these variables in a logistic regression model did not significantly improve the predictive capacity for mortality (to area under the curve 0.93 [0.85 to 0.97]) or morbidity (to area under the curve 0.67 [0.55 to 0.78]). In conclusion, the POSSUM score provides clinically useful predictive capacity in patients undergoing surgery for upper gastrointestinal malignancies. The incorporation of ICU admission variables to the pre- and intraoperative POSSUM variables did not significantly enhance the precision.
The Changing Face of Malignant Hyperthermia: Less Fulminant, More Insidious
Authors: Heytens L. , Forget P. , Scholtès J. L. , Veyckemans F.
Published: January 2019

Modern anaesthetic techniques have resulted in the clinical presentation of malignant hyperthermia to be more often indolent and/or insidious than truly fulminant, as previously known in the anaesthetic community. We present four recently referred cases to illustrate this point: one late-onset case, two patients with slowly progressive hypercapnia as the sole sign and a fourth patient with postoperative myalgias and elevated creatine kinase. We also discuss the reasons for the shift in typical clinical presentation. The more insidious character of malignant hyperthermia is most likely due to the lower triggering potency of modern volatile anaesthetics, the mitigating effects of several intravenous drugs (neuromuscular blocking agents, alpha 2 adrenergic receptor agonists, beta-adrenergic blockade) or techniques (neuraxial anaesthesia) and the routine use of end-tidal CO2 monitoring leading to the early withdrawal of triggering drugs. Awareness among anaesthetists of this change in presentation is important since the clinical diagnosis is often more doubtful and, if corroborative evidence is not sought, the diagnosis may be delayed or missed altogether.
The Non-Technical Skills Used by Anaesthetic Technicians in Critical Incidents Reported to the Australian Incident Monitoring System between 2002 and 2008
Authors: Rutherford J. S. , Flin R. , Irwin A.
Published: January 2019

The outcome of critical incidents in the operating theatre has been shown to be influenced by the behaviour of anaesthetic technicians (ATs) assisting anaesthetists, but the specific non-technical skills involved have not been described. We performed a review of critical incidents (n=1433) reported to the Australian Incident Monitoring System between 2002 and 2008 to identify which non-technical skills were used by ATs. The reports were assessed if they mentioned anaesthetic assistance or had the boxes ticked to identify “inadequate assistance” or “absent supervision or assistance”. A total of 90 critical incidents involving ATs were retrieved, 69 of which described their use of non-technical skills. In 20 reports, the ATs ameliorated the critical incident, whilst in 46 they exacerbated the critical incident, and three cases had both positive and negative nontechnical skills described. Situation awareness was identified in 39 reports, task management in 23, teamwork in 21 and decision-making in two, but there were no descriptions of issues related to leadership, stress or fatigue management. Situation awareness, task management and teamwork appear to be important non-technical skills for ATs in the development or management of critical incidents in the operating theatre. This analysis has been used to support the development of a non-technical skills taxonomy for anaesthetic assistants.
Necrotising Soft Tissue Infections: The Effect of Hyperbaric Oxygen on Mortality
Authors: Devaney B. , Frawley G. , Frawley L. , Pilcher D. V.
Published: January 2019

In a single-centre, retrospective, case-controlled study of patients attending the Alfred Hospital in Prahran, Victoria, we assessed the effect of hyperbaric oxygen therapy (HBOT) in reducing mortality or morbidity in patients with necrotising fasciitis (NF) over a 13-year period from 2002 to 2014. A total of three hundred and forty-one patients with NF were included in the study, of whom 275 received HBOT and 66 did not. The most commonly involved sites were the perineum (33.7%), lower limb (29.9%) and trunk (18.2%). The commonest predisposing factor was diabetes mellitus (34.8%). Polymicrobial NF (type 1 NF) occurred in 50.7% and Group A streptococcal fasciitis (type 2 NF) occurred in 25.8% of patients. Mortality was 14.4% overall, 12% in those treated with, and 24.3% in those not treated with, HBOT. ICU support was required in 248 (72.7%) patients. Independent factors impacting on mortality included HBOT (odds ratio [OR] 0.42 [0.22 to 0.83], P=0.01), increased age (OR 1.06 [1.03 to 1.08], P=0.001) and immunosuppression (OR 2.6 [1.23 to 5.51], P=0.01). Mortality was linked to illness severity at presentation, however when adjusted for severity score and need for intensive care management, HBOT was associated with significant reduction in mortality.
Overcoming Barriers to the Mobilisation of Patients in an Intensive Care Unit
Authors: Dafoe S. , Chapman M. J. , Edwards S. , Stiller K.
Published: January 2019

We conducted a quality improvement project aimed at increasing the frequency of mobilisation in our ICU. We designed a four-part quality improvement project comprising: an audit documenting the baseline frequency of mobilisation; a staff survey evaluating perceptions of the barriers to mobilisation; identification of barriers that were amenable to change and implementation of strategies to address these; and a follow-up audit to determine their effectiveness. The setting was a tertiary care, urban, public hospital ICU in South Australia. All patients admitted to the ICU during the two audit periods were included in the audits, while all permanent/semi-permanent ICU staff were eligible for inclusion in the staff survey. We found that patient- and institution-related factors had the greatest impact on the mobilisation of patients in our ICU. Barriers identified as being amenable to change included insufficient staff education about the benefits of mobilisation, poor interdisciplinary communication and lack of leadership regarding mobilisation. Various strategies were implemented to address these barriers over a three-month period. Multivariable analyses showed that three out of four mobility outcomes did not significantly change between the baseline and follow-up audits, with a significant difference in favour of the baseline audit found for the fourth mobility outcome (maximum level of mobility). We concluded that implementing relatively simple measures to improve staff education, interdisciplinary communication and leadership regarding early progressive mobilisation was ineffective at improving mobility outcomes for patients in a large tertiary-level Australian ICU. Other strategies, such as changing sedation practices and/or increasing staffing, may be required to improve mobility outcomes of these patients.
The Effects of Haemodilution with Hydroxyethyl Starch 130/0.4 Solution on Coagulation as Assessed by Thromboelastography and Platelet Receptor Function Studies in Vitro
Authors: Williams P. , Yang K. , Kershaw G. , Wong G. , Dunkley S. , Kam P. C. A.
Published: January 2019

This study evaluated the effects of haemodilution with either 6% hydroxyethyl starch (HES) 130/0.4 (Voluven®) or 0.9% normal saline (NS) on blood coagulation in vitro. Haemodilution with 6% HES 130/0.4 impaired coagulation, as indicated by the changes in thromboelastographic parameters k-time, α-angle and maximum amplitude. Light transmission aggregometry and multiple electrode aggregometry demonstrated that impaired platelet receptor function occurred only at high levels of haemodilution (40%) with both fluids, but there was no significant difference between the two fluids ( P=0.05). The thromboelastographic functional fibrinogen assay showed that the fibrinogen component of clot strength was significantly impaired with haemodilution with HES 130/0.4 compared with haemodilution with NS (whole blood [14.4±4.6 mm] versus 40% HES dilution [3.7±1.9], [ P=0.001]; versus 40% NS dilution [10.4±4.6], [ P=0.129]). These findings suggest that there is little difference between HES or NS in relation to coagulation or platelet function during minor or moderate haemodilution, but at high levels of haemodilution with HES, fibrinogen activity is more impaired compared with NS.
Effects of Dialysis Modality on Blood Loss, Bleeding Complications and Transfusion Requirements in Critically Ill Patients with Dialysis-Dependent Acute Renal Failure
Authors: Pschowski R. , Briegel S. , Von Haehling S. , Doehner W. , Bender T. O. , Pape U. F. , Hasper D. , Jörres A. , Schefold J. C.
Published: January 2019

Blood loss and bleeding complications may often be observed in critically ill patients on renal replacement therapies (RRT). Here we investigate procedural (i.e. RRT-related) and non-procedural blood loss as well as transfusion requirements in regard to the chosen mode of dialysis (i.e. intermittent haemodialysis [IHD] versus continuous veno-venous haemofiltration [CVVH]). Two hundred and fifty-two patients (122 CVVH, 159 male; aged 61.5±13.9 years) with dialysis-dependent acute renal failure were analysed in a sub-analysis of the prospective randomised controlled clinical trial—CONVINT—comparing IHD and CVVH. Bleeding complications including severity of bleeding and RRT-related blood loss were assessed. We observed that 3.6% of patients died related to severe bleeding episodes (between group P=0.94). Major all-cause bleeding complications were observed in 23% IHD versus 26% of CVVH group patients ( P=0.95). Under CVVH, the rate of RRT-related blood loss events (57.4% versus 30.4%, P=0.01) and mean total blood volume lost was increased (222.3±291.9 versus 112.5±222.7 ml per patient, P <0.001). Overall, transfusion rates did not differ between the study groups. In patients with sepsis, transfusion rates of all blood products were significantly higher when compared to cardiogenic shock (all P <0.01) or other conditions. In conclusion, procedural and non-procedural blood loss may often be observed in critically ill patients on RRT. In CVVH-treated patients, procedural blood loss was increased but overall transfusion rates remained unchanged. Our data show that IHD and CVVH may be regarded as equivalent approaches in critically ill patients with dialysis-dependent acute renal failure in this regard.
Anaphylaxis following Intravenous Paracetamol: The Problem is the Solution
Authors: Jain S. S. , Green S. , Rose M.
Published: January 2019

Paracetamol is a ubiquitous analgesic and antipyretic that is widely administered, including by anaesthetists. Immediate hypersensitivity reactions to intravenous paracetamol are particularly rare. We report two cases involving four separate episodes of anaphylaxis to intravenous paracetamol in different perioperative settings without a past history of intolerance to the oral form. The allergological investigations are described, during which it became evident that both patients were allergic to an excipient (mannitol) present in the formulation and that neither was allergic to the principal agent (paracetamol). The importance of referral and investigation of perioperative drug reactions is underscored by these two cases.