bluuebunny/crossref_metadata_2025 huggingface dataset:
Is There Evidence to Support the Use of Lateral Positioning in Intensive Care? A Systematic Review
Authors: Thomas P. J. , Paratz J. D.
Published: January 2019

A systematic review of randomised clinical trials was conducted to investigate the efficacy and safety of use of the lateral position in the management of ventilated intensive care patients. One review article and 11 empiric studies, which were mostly of low methodological quality, met the eligibility criteria. Large individual variations in PaO2 response to lateral positioning were demonstrated. Greatest improvement in PaO2 occurred in patients with unilateral pulmonary infiltrates positioned with the bad lung up versus bad lung down (average difference=33.6 mmHg (range 0-58), effect size 1.13 (95% CI: 0.44, 1.19, P=0.001)) or supine (average difference=27 mmHg (range 5-42), effect size 0.58 (95% CI: 0.11, 1.06, P=0.017)). This effect appeared to be most prominent in patients with widespread, unilateral infiltrates. Lung compliance was not affected by lateral positioning. Haemodynamic compromise was evident with lateral positioning of greater than 60° to the right side in patients requiring vasopressors and/or with right ventricular dysfunction; or with lateral positioning in postoperative coronary artery bypass graft patients. No studies were found that had investigated the effect of routine applications of the lateral positioning to improve, prevent or treat pneumonia, decrease mortality or influence other long-term outcomes. The results of this review demonstrate the limited evidence available to support the use of lateral positioning in the intensive care environment. More data reporting the long-term effects of lateral position on long-term outcomes would aid clinical decision making and may improve the application of patient positioning in critical care environments.
The Use of Statins in Intensive Care Unit Patients with Sepsis
Authors: Bromilow J. , Bruce M. J. L. Schuster
Published: January 2019

The incidence of sepsis is increasing and remains the leading cause of death in critically ill patients. The statin group of drugs appear to have important antiinflammatory effects and may have a role in the treatment of sepsis. However, current prescribing guidelines recommend that statin therapy is discontinued in critically ill patients. We found no evidence to support commencing statin therapy in patients with sepsis on an intensive care unit and low levels of evidence to support continuing established therapy in this patient population.
ICU Staffing: Identification and Survey of Staff Involved in Providing Technical Support Services to Australian and New Zealand Intensive Care Units
Authors: Carter B. G. , Kiraly N. , Hochmann M. , Stephens R. , Osborne A.
Published: January 2019

We conducted a survey of all (200) Australian and New Zealand intensive care units to determine the presence and nature of staff employed in a technical support role. Specifically, we attempted to identify staff who are formally employed in a role where they are directly responsible for the equipment used in intensive care. Of 130 returned surveys, 80 units (62%) reported not having any personnel in this role. In these units technical tasks were most commonly performed by registered nurses (79%) but were also performed by a variety of other personnel. Fifty units (38%), consisting of approximately 105 individuals providing a total of 84.3 EFTs and most commonly in public (84%) or metropolitan (70%) hospitals or level 3 (64%) intensive care units, did have one or more staff acting in a formal technical support role. The most common groups filling the technical support role were nurses (42%), technicians (24%), biomedical engineers (10%) and technologists (6%). The most common duties performed were equipment troubleshooting (92%), training (80%), equipment evaluation (80%), ordering supplies (77%), consumable evaluation (75%), equipment cleaning (73%), delivery of supplies (70%), handling product recalls (65%), equipment maintenance (65%) and sitting on hospital committees (52%). This is the first attempt to identify and understand the technical support role in Australian and New Zealand intensive care units. Numerous issues remain and future work will hopefully add to our findings, with the possibility of formal recognition of the role, training and/or accreditation and its extension into other hospital departments.
Acute Pulmonary Embolectomy Three Days following a Coronary Artery Bypass Graft Procedure
Authors: Kuklinski D. , Tevaearai H. T. , Eckstein F. S. , Carrel T. P.
Published: January 2019

Pulmonary embolism is very rarely reported early after cardiac surgery, most probably due to full heparinisation during cardiopulmonary bypass. We report a 66-year-old man without thromboembolic history who presented three days after a coronary artery bypass grafting procedure with acute dyspnoea and haemodynamic instability. A CT scan confirmed paracentral bilateral pulmonary embolism requiring an urgent and successful embolectomy. Review of the literature confirms that pulmonary embolism may occur in up to 3% of post-cardiopulmonary bypass patients.

The possibility of pulmonary embolism must be taken into consideration in post-cardiopulmonary bypass patients with acute onset of chest pain and respiratory insufficiency.
Impact of Bispectral Index Monitoring on Propofol Administration in Patients Undergoing Cardiopulmonary Bypass
Authors: Chiu C. L. , Ong G. , Majid A. A.
Published: January 2019

Propofol anaesthesia using target control infusion during cardiac surgery has become more popular recently. However, without depth of anaesthesia monitoring, the standard target concentration used may be higher than necessary to maintain adequate hypnosis during hypothermic cardiopulmonary bypass. The purpose of this study was to evaluate the effect of bispectral index monitoring on propofol administration during hypothermic cardiopulmonary bypass. After ethics committee approval and written informed consent, 20 New York Heart Association class I-III patients scheduled for elective cardiac surgery requiring hypothermic cardiopulmonary bypass were studied in this prospective randomised controlled trial. In group C, routine anaesthesia was practised, where patients received propofol at target concentration between 1.5 to 2.5 μ/ml during cardiopulmonary bypass. In group B, the target concentration was titrated to a bispectral index value of 40 to 50. Mean arterial pressure and bispectral index were recorded at various time intervals. The use of propofol, phenylephrine, sodium nitroprusside and adrenaline were recorded. The median propofol administration in group B was significantly less than that in group C (2.9 mg/kg/h compared to 6.0 mg/kg/h). The bispectral index value during bypass was significantly lower in group C than in group B, reflecting a deeper state of anaesthesia. There was no difference in the use of inotropes, vasoconstrictors or vasodilators. Bispectral index monitoring enables a 50% reduction in propofol administration at this standard dose during hypothermic cardiopulmonary bypass.
Bispectral Index as a Predictor of Sedation Depth during Isoflurane or Midazolam Sedation in ICU Patients
Authors: Sackey P. V. , Radell P. J. , Granath F. , Martling C. R.
Published: January 2019

Bispectral index (BIS) is used for monitoring anaesthetic depth with inhaled anaesthetic agents in the operating room but has not been evaluated as a monitor of sedation depth in the intensive care unit (ICU) setting with these agents. If BIS could predict sedation depth in ICU patients, patient disturbances could be reduced and oversedation avoided. Twenty ventilator-dependent ICU patients aged 27 to 80 years were randomised to sedation with isoflurane via the AnaConDa® or intravenous midazolam. BIS (A-2000 XP, version 3.12), electromyogram activity (EMG) and Signal Quality Index were measured continuously. Hourly clinical evaluation of sedation depth according to Bloomsbury Sedation Score (Bloomsbury) was performed. The median BIS value during a 10-minute interval prior to the clinical evaluation at the bedside was compared with Bloomsbury. Nurses performing the clinical sedation scoring were blinded to the BIS values. End-tidal isoflurane concentration was measured and compared with Bloomsbury. Correlation was poor between BIS and Bloomsbury in both groups (Spearman's rho 0.012 in the isoflurane group and -0.057 in the midazolam group). Strong correlation was found between BIS and EMG (Spearman's rho 0.74). Significant correlation was found between end-tidal isoflurane concentration and Bloomsbury (Spearman's rho 0.47). In conclusion, BIS XP does not reliably predict sedation depth as measured by clinical evaluation in non-paralysed ICU patients sedated with isoflurane or midazolam. EMG contributes significantly to BIS values in isoflurane or midazolam sedated, non-paralysed ICU patients. End-tidal isoflurane concentration appeared to be a better indicator of clinical sedation depth than BIS.
Stability of the Strong Ion Gap versus the Anion Gap over Extremes of PCO2 and pH
Authors: Morgan T. J. , Cowley D. M. , Weier S. L. , Venkatesh B.
Published: January 2019

The strong ion gap (SIG) is under evaluation as a scanning tool for unmeasured ions. SIG is calculated by subtracting [buffer base], which is ([A-]+[HCO3-]), from the apparent strong ion difference, which is ([Na+] + [K+]+[Ca++]+[Mg++]-[Cl-]-[L-lactate]). A- is the negative charge on albumin and phosphate. We compared the pH stability of the SIG with that of the anion gap (AG).

In normal and hypoalbuminaemic hyperlactaemic blood, PCO2 was reduced stepwise in vitro from >200 mmHg to < 20 mmHg, with serial blood gas and electrolyte analyses, and [albumin] and [phosphate] measurement on completion.

Respective [haemoglobin], [albumin], [phosphate] and [lactate] in normal blood were 156 (0.9) g/l, 44 (2) g/l, 1.14 (0.06) mmol/l and 1.7 (0.8) mEq/l, and in hypoalbuminaemic blood 116 (0.9) g/l, 24 (2) g/l, 0.78 (0.06) mmol/l and 8.5 (0.5) mEq/l. pH increased from <6.85 to >7.55, causing significant falls in [Na+] and elevations in [Cl-]. Initial and final SIG values did not differ, showing no correlation with pH. Mean SIG was 0.5±1.5 mEq/l. AG values were directly correlated with pH (normal: R2=0.51, hypoalbuminaemic: R2=0.65). Final AG values significantly exceeded initial values (normal blood: 15.9 (1.7) mEq/l versus 8.9 (1.8) mEq/l, P<0.01; hypoalbuminaemic blood: 16.5 (0.8) mEq/l versus 11.8 (2.0) mEq/l, P<0.05).

We conclude that, unlike the AG, the SIG is not affected by severe respiratory acidosis and alkalosis, enhancing its utility in acid-base disturbances.
The Diagnostic Yield and Clinical Impact of a Chest X-Ray after Percutaneous Dilatational Tracheostomy: A Prospective Cohort Study
Authors: Haddad S. H. , Aldawood A. S. , Arabi Y. M.
Published: January 2019

A chest X-ray (CXR) is routinely performed after percutaneous dilatational tracheostomy (PDT). The purpose of this study was to evaluate the diagnostic yield of routine CXR following PDT and its impact on patient management and to identify predictors of post-PDT CXR changes. Two-hundred-and-thirty-nine patients who underwent PDT in a 21-bed intensive care unit were included prospectively in the study. The following data were collected: patient demographics, APACHE III scores, pre-PDT FiO2 and PEEP, PDT technique, perioperative complications and the use of bronchoscopic guidance. We compared post-PDT CXR with the last pre-PDT CXR. We documented any post-PDT new radiographic findings including atelectasis, pneumothorax, pneumomediastinum, surgical emphysema, pulmonary infiltrates or tracheostomy tube malposition. We also recorded management modifications based on post-PDT radiographic changes, including increased PEEP, chest physiotherapy, therapeutic bronchoscopy or chest tube insertion. Atelectasis was the only new finding detected on post-PDT CXRs of 24 (10%) patients. The new radiographic findings resulted in a total of 14 modifications of management in 10 (4%) patients including increased PEEP in six, chest physiotherapy in six and bronchoscopy in two patients. Trauma and pre-PDT PEEP >5 cmH2O were independent predictors of post-PDT CXR changes. Routine CXR following PDT has a low diagnostic yield, detecting mainly atelectasis and leading to a change in the management in only a minority of patients. Routine CXR after apparently uncomplicated PDT performed by an experienced operator may not be necessary and selective use may improve its diagnostic yield. Further studies are required to validate the safety of selective versus routine post-PDT CXR.
Retrieval of an Endobronchial Foreign Body Using a Guide Wire and Angioplasty Catheter
Authors: Briggs G. , Walker R. W. M.
Published: January 2019

We report the use of a guide wire and angioplasty balloon catheter to retrieve an endobronchial foreign body after failure of conventional techniques. The foreign body was a pen top that had a small lumen, which allowed passage of the wire and use of the balloon catheter for retrieval. The difficulty of retrieval of such objects and the limitations of the equipment usually used for this procedure are discussed.
Combining Sequential Organ Failure Assessment (SOFA) Score with Acute Physiology and Chronic Health Evaluation (APACHE) II Score to Predict Hospital Mortality of Critically Ill Patients
Authors: Ho K. M.
Published: January 2019

The ability to accurately adjust for the severity of illness in outcome studies of critically ill patients is essential. Previous studies have showed that Sequential Organ Failure Assessment (SOFA) score and Acute Physiology and Chronic Health Evaluation (APACHE) II score can predict hospital mortality of critically ill patients. The effects of combining these two scores to predict hospital mortality of critically ill patients has not been evaluated. This cohort study evaluated the performance of combining the APACHE II score with SOFA score in predicting hospital mortality of critically ill patients. A total of 1,311 consecutive adult patients admitted to a tertiary 22-bed multidisciplinary intensive care unit (ICU) in Western Australia were considered. The APACHE II, Admission SOFA, Delta SOFA and maximum SOFA score were all related to hospital survival in the univariate analyses. Combining Max SOFA (area under receiver operating characteristic curve 0.875 vs. 0.858, P=0.014; Nagelkerke R2: 0.411 vs. 0.371; Brier Score: 0.086 vs. 0.090) or Delta SOFA score (area under receiver operating characteristic curve 0.874 vs. 0.858, P=0.003; Nagelkerke R2: 0.412 vs. 0.371; Brier Score: 0.086 vs. 0.090) with the APACHE II score improved the discrimination and overall performance of the predictions when compared with using the APACHE II score alone, especially in the emergency ICU admissions. Combining Max SOFA or Delta SOFA score with the APACHE II score may improve the accuracy of risk adjustment in outcome studies of critically ill patients.
Patients’ Knowledge of the Qualifications and Roles of Anaesthetists
Authors: Braun A. R. , Leslie K. , Morgan C. , Bugler S.
Published: January 2019

Patients’ knowledge of anaesthetists’ qualifications and roles remains inaccurate despite the efforts of professional bodies worldwide. However, patients have not been surveyed on this subject in Australia for more than 20 years. We therefore surveyed 200 patients attending the pre-admission clinic prior to elective non-cardiothoracic surgery in an Australian teaching hospital to determine current knowledge. Most (90.5%) patients stated that anaesthetists are medically qualified and 83.5% stated that they are medical specialists. Younger age, an English-speaking background and previous experience with surgery predicted knowledge of anaesthetists’ qualifications. Most patients believed that anaesthetists work in the operating theatre and are continually present during surgery, but few recognised their leading role in the care of patients during surgery or their other roles outside the operating theatre. Increased efforts are required to inform patients about the roles of anaesthetists in their care.
The Shoulder Block: A New Alternative to Interscalene Brachial Plexus Blockade for the Control of Postoperative Shoulder Pain
Authors: Price D.J.
Published: January 2019

This report describes the development of the shoulder block, an alternative to interscalene brachial plexus blockade for the control of postoperative pain following shoulder surgery. Included is a review of the relevant anatomy of the shoulder joint and its associated structures. Two nerves provide the bulk of the innervation to this area: the suprascapular nerve and the axillary (circumflex) nerve. The shoulder block technique involves selective blockade of both of these nerves instead of general blockade of the entire brachial plexus via the interscalene route. The technique of Meier is used to block the suprascapular nerve in the supraspinous fossa. No descriptions of axillary nerve block were available in the literature, so a technique for blocking this nerve as it travels across the posterior surface of the humerus was developed and is described, along with a discussion of the author's initial clinical experience.
Investigation of a New Echogenic Needle for use with Ultrasound Peripheral Nerve Blocks
Authors: Deam R. K. , Kluger R. , Barrington J. , McCutcheon C.A.
Published: January 2019

A new ‘texturing method’ has been developed for nerve block needles in an attempt to improve the ultrasonic image of the needles. Using a synthetic phantom, these textured needles were compared to currently available needles. The textured needle had improved visibility under ultrasound. This type of needle may assist the anaesthetist perform ultrasound-guided regional anaesthesia.
Learning and Teaching in Small Groups: Characteristics, Benefits, Problems and Approaches
Authors: Jones R. W.
Published: January 2019

Small group learning may be defined as a group of learners demonstrating three common characteristics; active participation, a specific task and reflection. This article provides an overview of small group learning and teaching, describes the characteristics of this form of small group work, benefits, problems, potential causes of less than optimal sessions, and summarises specific approaches. These include tutorials, free-discussion groups, brainstorming, snowballing, buzz groups, paired (or one-to-one) discussion, clinical teaching, simulations, seminars, plenary sessions, problem-based learning, team-based learning, role plays, games and IT approaches. The article concludes with an emphasis on the importance of the teacher and a check list for use when planning, teaching and evaluating a small group session.
Postoperative Paraplegia Coincident with Single Shot Spinal Anaesthesia
Authors: Laferlita B. W.
Published: January 2019

Paraplegia is a rare but serious complication of spinal anaesthesia. We report an 83-year-old patient who developed anterior spinal artery syndrome resulting in paraplegia some 24 hours after undergoing spinal anaesthesia for a Moore's hemiarthroplasty. Return of neurologic function was documented prior to the onset of paralysis, with magnetic resonance imaging evidence suggestive of spinal cord infarction.
Posterior Fossa Haematoma following Sudden Decompression of Acute Hydrocephalus Resulting from Neuroendoscopy
Authors: Prabhakar H. , Ali Z. , Rath G. P.
Published: January 2019

We report a case of a 47-year-old male undergoing endoscopic removal of a third ventricular colloid cyst. After uneventful surgery, the patient remained drowsy and was transferred to the intensive care unit for supportive care. In the postoperative period, the patient developed hydrocephalus due to clot in the region of the cyst. A posterior fossa haematoma and further neurological deterioration complicated external ventricular drainage, presumably due to sudden intracranial hypotension. Gradual ventricular decompression is recommended to reduce the risk of this complication.
Sildenafil May Facilitate Weaning in Mechanically Ventilated COPD Patients: A Report of Three Cases
Authors: Stanopoulos I. , Manolakoglou N. , Pitsiou G. , Trigonis I. , Tsiata E. A. , Boutou A. K. , Kontou P. K. , Argyropoulou P.
Published: January 2019

We report three cases of mechanically ventilated chronic obstructive pulmonary disease patients who were intubated due to an exacerbation of their disease and who presented with repeated spontaneous breathing trial failures. Patients were given 50 mg of sildenafil through the nasogastric tube, under close monitoring of haemodynamic and ventilatory parameters. After sildenafil, pulmonary artery pressure, pulmonary artery occlusion pressure, the respiratory frequency to tidal volume ratio and the PCO2-PETCO2 (arterial minus end-tidal carbon dioxide pressure) decreased. Cardiac output increased in two of the patients, while all of them were successfully extubated. This is the first report of successful extubation after sildenafil use.
Introduction and Audit of Intravenous Paracetamol at a Tertiary Paediatric Teaching Hospital
Authors: Palmer G. M. , Chen S. P. , Smith K. R. , Hardikar W.
Published: January 2019

Although intravenous (IV) paracetamol is an attractive analgesic, there is little information on its paediatric use. During an introduction phase with limited prescribing rights, an audit was performed to assess its use and cost impact at a tertiary paediatric centre. Patients receiving IV paracetamol prescribed by two pain specialists for restricted indications had their medical records retrospectively reviewed for age, weight, diagnosis, indications/dose for IV (and other route) paracetamol/other analgesics/antiemetics, vomiting/oral intake and liver function tests if performed. One-hundred-and-twenty-one children and five neonates received 1216 (median 8 each) doses of paracetamol IV. Audited expenditure for IV paracetamol was 3.9 times the rectal alternative ($3435 vs. $875). Indications were appropriate, with 97% of patients nil oral, 41% vomiting, 17% having rectal route replaced and 3% avoiding parenteral morphine. Only five patients received incorrect dosing: three through prescription errors and two as guideline deviations; none were considered dangerous. No liver function test derangements could be directly attributed to paracetamol.

This data facilitated our application to extend prescribing rights for IV paracetamol within our institution. As there is limited information or local experience with the use of IVparacetamol in paediatric settings in Australia, our data may be of use to other centres considering the introduction of the IV form of this agent.
Atrial Fibrillation in a Tertiary Care Multidisciplinary Intensive Care Unit—Incidence and Risk Factors
Authors: Arora S. , Lang I. , Nayyar V. , Stachowski E. , Ross D. L.
Published: January 2019

Atrial fibrillation is a common arrhythmia in an intensive care unit. We performed a prospective observational study over a period of three months, to study the incidence, risk factors and outcome of patients who develop atrial fibrillation in a multidisciplinary intensive care unit. All patients above the age of 50 years were eligible. Exclusion criteria were: cardiac or oesophageal surgery during current hospitalisation, atrial fibrillation at admission, implanted pacemaker and expected intensive care unit stay of less than 24 hours.

Sixty-one patients were included in the study. Eighteen patients (29.5%, confidence interval 18-40) developed atrial fibrillation. Incidence of atrial fibrillation was 4.02 episodes per 100 patient days. Patients who developed atrial fibrillation had higher age (71.3 years vs. 63.2 years, P=0.001), severity of illness (APACHE II 25.4 vs. 20.0, P=0.005) and sepsis at admission (9/18 vs. 9/43, P=0.01). They also had higher in-hospital mortality (Risk ratio 2.7, 95% confidence interval 1.3-5.4). Standardised mortality ratio was higher in patients who developed atrial fibrillation (1.08 vs. 0.63). Patients who developed atrial fibrillation required a longer period of mechanical ventilation and inotropic support. Multivariate logistic regression analysis showed age > 75 years, APACHE II score >20 and sepsis at admission were independent predictors for development of atrial fibrillation in critically ill patients. Although atrial fibrillation by itself is unlikely to be the cause of higher mortality, it is likely to be a marker for increased mortality and resource utilisation in the intensive care unit.
Comparative evaluation of Myolaxin and EM LA cream for attenuation of venous cannulation pain: A prospective, randomised, double blind study
Authors: Agarwal A. , Yadav G. , Gupta D. , Tandon M. , Dhiraaj S. , Singh P. K.
Published: January 2019

We evaluated the efficacy of topical Myolaxin (capsaican ointment, Geno, Mumbai) ointment over EMLA (eutectic mixture of lignocaine, prilocaine; Neon, Goa) cream for attenuating venous cannulation pain in this prospective, randomised, double blind study. Sixty adult patients undergoing elective laparoscopic cholecystectomy were randomly assigned into two equal groups. Group I (EMLA) received EMLA cream, whereas Group II (Myolaxin) received Myolaxin ointment. For both groups the cream was applied at the venous cannulation site (dorsum of the non-dominant hand) one hour prior to venous cannulation and was covered with an occlusive dressing. Following venous cannulation patients were asked if they felt pain during venous cannulation. If the answer was yes, they were asked to rate the severity of venous cannulation pain using a Visual Analogue Scale (VAS) of O-10. The incidence of venous cannulation pain was similar between groups: in the EMLA group 65% (18/28) compared to 67% (20/30) in the Myolaxin group (P=0.19). The severity of pain (median VAS with inter quartile range) was also similar between the groups: in the EMLA group 1.5 (3) compared to 1.5 (2) in the Myolaxin group (P=0.46). As the topical application of Myolaxin ointment is cheaper than EMLA and has similar efficacy, it may be a suitable alternative for reducing the incidence and severity of venous cannulation pain.
Effects of Reduction of the Caudal Morphine Dose in Paediatric Circumcision on Quality of Postoperative Analgesia and Morphine-Related Side-Effects
Authors: Cesur M. , Alici H. A. , Erdem A. F. , Yapanoglu T. , Silbir F.
Published: January 2019

This study compared the efficacy and adverse effects of three low doses of morphine (10, 15 and 30 μg.kg1) for caudal epidural analgesia in children undergoing circumcision. A total of 135 boys undergoing outpatient circumcision were randomly assigned to receive 10, 15 or 30 μg.kg1 of caudal morphine. Anaesthesia was induced and maintained with propofol. After induction, the morphine was added to 0.5 ml.kg1 1% lignocaine solution with adrenaline 5μg.ml1 and injected caudally. Anaesthesia quality, postoperative pain and adverse events in a 24-hour period were evaluated. Paracetamol (20 mg. kg’ orally) was used as rescue analgesia as required.

No patient required paracetamol in the first eight hours after the caudal injections. In the first 24 hours postoperatively no further analgesia was required in 66.7%, 77.8% and 91.1% of the patients in the 10, 15 and 30 μg.kg1 groups, respectively (P=0.01 for 10 vs. 30 groups). All patients had excellent analgesia. No respiratory complications were observed. Nausea-vomiting occurred in 13.3%, 20% and 46.7% of the patients in the 10, 15 and 30 μg.kg1 groups (P=0.002 for 10 vs. 30 and 0.044 for 15 vs. 30). Pruritus occurred in 8.9%, 11% and 15.6% in the 10, 15 and 30 μg.kg1 groups but was localised and did not require treatment.

This study was not powered to assess concerns that low dose epidural morphine may rarely be associated with delayed apnoea and is therefore considered unsuitable for outpatient use in many centres. Increases in caudal morphine dose above 10 μxg. kg1 produce some ‘paracetamol sparing’ but no improvement in analgesia, some pruritus and a significant increase in nausea and vomiting.
Hypotension and Anaemia—A Blinding Combination
Authors: Hughes E. H. , Graham E. M. , Wyncoll D. L. A.
Published: January 2019

We present a case of complete blindness following severe dengue haemorrhagic fever complicated by anaemia and a dialysis-related episode of profound hypotension. The clinical and radiological features indicated an optic neuropathy, most likely ischaemic in aetiology. The features of posterior ischaemic optic neuropathy and differential diagnosis are discussed.
Unsuccessful Lumbar Puncture in a Paediatric Patient with Achondroplasia
Authors: Burgoyne L. L. , Laningham F. , Zero J. T. , Bikhazi G. B. , Pereiras L. A.
Published: January 2019

We present a case of an unsuccessful lumbar puncture performed on an anaesthetised 17-year-old girl with achondroplasia who was diagnosed with and being treated for acute lymphoblastic leukaemia. Magnetic resonance imaging (MRI) subsequently showed spinal stenosis and no observable cerebrospinal fluid around the nerve roots at the levels of the lumbar pedicles and discs. A recommendation is made to obtain MRI scans before proceeding with lumbar puncture and/or spinal anaesthesia in this patient group to ensure that the anatomical features of the insertion site are favourable to a successful outcome.
Perioperative Management of Sickle Cell Disease in Paediatric Cardiac Surgery
Authors: Bhatt K. , Cherian S. , Agarwal R. , Jose S. , Cherian K. M.
Published: January 2019

In sickle cell disease, cardiopulmonary bypass may induce red cell sickling. Partial exchange transfusion reduces the circulating haemoglobin S level. We report the management of a child with sickle cell disease who required surgical closure of a ventricular septal defect. Preoperative exchange transfusion of 50% of the total blood volume was performed with fresh packed red cells over three days. Further exchange transfusion was performed as cardiopulmonary bypass commenced. The haemoglobin S level was reduced from 76% to 37%. The blood removed from the patient during the exchanges was processed allowing storage and re-infusion of the patient's plasma and platelets. Combined preoperative and intraoperative exchange transfusions, instead of a single stage 50% volume exchange, was effective and potentially avoids larger haemodynamic effects. Cardiopulmonary bypass was conducted at normothermia and cold cardioplegia was avoided (fibrillatory arrest was used during the surgical repair).
Prediction of Successful Defibrillation in Human Victims of Out-of-Hospital cArdiac Arrest: A Retrospective Electrocardiographic Analysis
Authors: Ristagno G. , Gullo A. , Berlot G. , Lucangelo U. , Geheb F. , Bisera J.
Published: January 2019

In the present study we sought to examine the efficacy of an electrocardiographic parameter, ‘amplitude spectrum area’ (AMSA), to predict the likelihood that any one electrical shock would restore a perfusing rhythm during cardiopulmonary resuscitation in human victims of out-of-hospital cardiac arrest. AMSA analysis is not invalidated by artefacts produced by chest compression and thus it can be performed during CPR, avoiding detrimental interruptions of chest compression and ventilation. We hypothesised that a threshold value of AMSA could be identified as an indicator of successful defibrillation in human victims of cardiac arrest.

Analysis was performed on a database of electrocardiographic records, representing lead 2 equivalent recordings from automated external defibrillators including 210 defibrillation attempts from 90 victims of out-of-hospital cardiac arrest. A 4.1 second interval of ventricular fibrillation or ventricular tachycardia, recorded immediately preceding the delivery of the shock, was analysed using the AMSA algorithm. AMSA represents a numerical value based on the sum of the magnitude of the weighted frequency spectrum between two and 48 Hz.

AMSA values were significantly greater in successful defibrillation (restoration of a perfusing rhythm), compared to unsuccessful defibrillation (P <0.0001). An AMSA value of 12 mV-Hz was able to predict the success of each defibrillation attempt with a sensitivity of 0.91 and a specificity of 0.97.

In conclusion, AMSA analysis represents a clinically applicable method, which provides a realtime prediction of the success of defibrillation attempts. AMSA may minimise the delivery of futile and detrimental electrical shocks, reducing thereby postresuscitation myocardial injury.
Arterial Gas Embolism: A Review of Cases at Prince of Wales Hospital, Sydney, 1996 to 2006
Authors: Trytko B. E. , Bennett M. H.
Published: January 2019

Arterial gas embolism may occur as a complication of diving or certain medical procedures. Although relatively rare, the consequences may be disastrous. Recent articles in the critical care literature suggest the non-hyperbaric medical community may not be aware of the role for hyperbaric oxygen therapy in non-diving related gas embolism. This review is part of an Australian appraisal of experience in the management of arterial gas embolism over the last 10 years.

We identified all patients referred to Prince of Wales Hospital Department of Diving and Hyperbaric Medicine with a diagnosis of arterial gas embolism from 1996 to 2006. Twenty-six patient records met our selection criteria, eight iatrogenic and 18 diving related. All patients were treated initially with a 280 kPa compression schedule. At discharge six patients were left with residual symptoms. Four were left with minor symptoms that did not significantly impact quality of life. Two remained severely affected with major neurological injury. Both had non-diving-related arterial gas embolism.

There was a good outcome in the majority of patients who presented with arterial gas embolism and were treated with compression.
The Pulmonary Artery Catheter in Australasia: A Survey Investigating Intensive Care Physicians’ Knowledge and Perception of Future Trends in Use
Authors: Johnston I. G. , Fraser J. F. , Sabapathy S. , Kruger P. S.
Published: January 2019

A survey was conducted to assess the knowledge and trends of use of the pulmonary artery catheter amongst intensive care practitioners in Australasia.

A 31-item multiple choice questionnaire, identical to one previously trialled in studies in the United States and Europe, was distributed to all registered intensive care specialists and trainees working in intensive care units in Australasia.

Five-hundred-and-forty-one questionnaires were distributed and 151 (27.9%) were returned, with an average mark of 82.7%±9.3% and a range of 53.3 to 100%. Total score was significantly associated with years of experience in intensive care (P <0.04), number of pulmonary artery catheters inserted (P <0.015) and whether or not the respondent had passed the Joint Faculty of Intensive Care Medicine examination (P <0.01). Scores were significantly higher amongst trainees (P <0.0001) and physicians who had passed the Joint Faculty of Intensive Care Medicine examination (P <0.0001). Overall, 44.9% of respondents indicated their use of the pulmonary artery catheter was decreasing, with 42.6% indicating their use was the same over the past five years. Sixty-one percent of respondents indicated they either agreed or strongly agreed with the statement that the use of echocardiography should supersede the use of the pulmonary artery catheter by intensive care specialists in the future.

We concluded that in this study, knowledge of the pulmonary artery catheter and its use is better in Australasia than in previous studies in North America and Europe. The majority of respondents in Australasia believe that echocardiography will supersede the use of the pulmonary artery catheter in the future.
A Survey of the Use of Unapproved Medicines in Anaesthesia Practice in New Zealand
Authors: Julian K. A. , Stapelberg F.
Published: January 2019

The Medicines Act (1981) and its amendments regulate the manufacture, sale and supply of medicines, medical devices and related products in New Zealand. Medications are approved for supply under the provisions of this Act. Supply and administration of unapproved medications is permitted. When this occurs, the supplier must report this to the Director-General of Health. Additionally, the patient must be informed of the unapproved status of the drug and be advised of the forwarding of information related to their health care to a third party. For apparently commercial reasons, approval has not been sought for a number of formulations of medications commonly used in anaesthesia practice.

There has been no published literature of the impact of this legislation on the practice of anaesthesia in New Zealand. A survey was undertaken to determine how commonly anaesthetists administer unapproved drugs, whether the requirements for informed consent were met and any perceived impact the status of these medications has on patient care. The survey findings indicated that the majority of New Zealand anaesthetists practise ‘outside the law’ with respect to unapproved medicines. Seventy-eight percent do not inform patients about the potential use of unapproved medications during their anaesthetic, despite 65% administering these medications to patients “every few weeks” or even more often.
Cytomegalovirus Colitis in a Critically Ill Patient following Elective Repair of an Abdominal Aortic Aneurysm
Authors: Helgason K. O. , Raby S. J. M. , Kamel H. M. H. , Laurenson I. F. , Templeton K. , Walsh T. S.
Published: January 2019

We describe a case of cytomegalovirus colitis in a critically ill but otherwise immunocompetent 61-year-old male. Infection was demonstrated by histology and confirmed by plasma polymerase chain reaction and detection of cytomegalovirus IgM antibody. The patient was treated with ganciclovir with resolution of the cytomegalovirus viraemia. Cytomegalovirus colitis may be an under-recognised problem in immunocompetent patients who are critically ill. Quantification of plasma cytomegalovirus DNA by polymerase chain reaction is a non-invasive method of supporting the diagnosis and can be used to monitor the treatment of cytomegalovirus infection in the immunocompetent.
Insulin Infusion via an Intraosseous Needle in Diabetic Ketoacidosis
Authors: Alawi K. A. , Morrison G. C. , Fraser D. D. , Al-Farsi S. , Collier C. , Kornecki A.
Published: January 2019

We report the successful management of a five-year-old child with severe diabetic ketoacidosis with dehydration, who received his initial resuscitative fluids and a continuous infusion of insulin via an intraosseous needle. The patient had presented to a remote community hospital and intravenous access could not be gained. The correction of hyperglycaemia and metabolic acidaemia was achieved at a rate comparable to intravenous therapy. No complications were observed. Although intraosseous access is well described in paediatric resuscitation guidelines, it is not mentioned in International Diabetes Society guidelines for the management of diabetic ketoacidosis. Alternatives to intravenous administration of insulin delivery recommended in such guidelines, such as the subcutaneous or intramuscular routes, may be less appropriate than the intraosseous route. This route can also allow resuscitation fluids and other drugs to be reliably administered in children with diabetic ketoacidosis and severe dehydration where intravenous access can not be attained. We suggest that the potential role of intraosseous access, when intravenous access can not be obtained, should be considered when management guidelines for paediatric diabetic ketoacidosis with dehydration are reviewed.
The Use of Lee and Co-Workers’ Index to Assist a Risk Adjusted Audit of Perioperative Cardiac Outcome
Authors: Moran P. J. , Ghidella T. , Power G. , Jenkins A. S. , Whittle D.
Published: January 2019

Lee and co-workers’ revised cardiac risk index was used to study the perioperative cardiac outcome of 296 patients. The index uses a history of ischaemic heart disease, congestive cardiac failure, diabetes treated with insulin, a creatinine greater than 180 μmol/l, cerebrovascular disease and high risk surgery as the risk factors involved in predicting a perioperative cardiac event. It was derived on the basis of data from patients over the age of 50 years undergoing elective, noncardiac surgery with an expected inpatient stay of two or more days. The presence of one, two and three or more risk factors predicted a risk of a major cardiac event of 1.3% (95% confidence interval [CI] 0.7 to 2.1), 3.6% (95% CI 2.1 to 5.6) and 9% (95% CI 5.5 to 13.8) respectively in Lee's derivation group of 2,893 patients. In our audit of 296 patients we observed a cardiac event rate of 0.8% (95% CI 0 to 2.3%), 6.7% (95% CI 1.6 to 10%) and 2% (95% CI 0 to 5.9%), in patients with one, two and three or more risk factors respectively. The more frequent use of ECGs and troponin levels in the routine postoperative care of high risk patients undergoing major noncardiac surgery is recommended on the basis of the frequency of a positive result and the impact of a positive result on a patient's management.
Communication during Induction of Paediatric Anaesthesia: An Observational Study
Authors: Carlyle A. V. , Ching P. C. , Cyna A. M.
Published: January 2019

We aimed to identify and categorise advanced communication skills used by experienced consultant paediatric anaesthetists to facilitate the induction of paediatric anaesthesia. The communication techniques were both verbal and non-verbal. Communications with potentially negative effects were also noted. Eighty-three inductions were observed over a three-month period. The 12 anaesthetists observed were all senior consultants at a tertiary referral paediatric centre. The mean age of patients was 6.1 years SD±4.8. There were 53 males (63.9%) and 30 females (36.1%). A first anaesthetic was administered to 43 patients (56%) and sedative premedication to six (8%). Inhalational inductions were observed in 59 patients (71%). The remainder received an intravenous induction. Anaesthesia was induced in the operating room on 68 occasions (82%), in the induction room on 11 (13%) and in the radiology department on 4(5%). The most common communication techniques used were: voice change in 60 (72%); distraction in 49 (59%); direct commands in 39 (47%); repetition in 34 (41%); imagery in 21 (25%) and focused attention 21 (25%). Other techniques used were seeding of ideas, utilisation, non-verbal cues, double-binds, story-telling, indirect suggestion, dissociation and reversed effect. Sabotage by parents or staff, such as inadvertent negative suggestions, was observed on 14 occasions (17%). Paediatric anaesthetists utilise a wide range of communication techniques in a highly flexible manner when inducing anaesthesia in children. Many of these communications can be characterised as hypnotherapeutic. Our observations suggest that formal structured training in communication skills and further research is warranted.
Generalisability of Behavioural Skills in Simulated Anaesthetic Emergencies
Authors: Weller J. M. , Jolly B. , Robinson B.
Published: January 2019

A reliable assessment of clinical performance requires multiple cases, as performance varies between cases depending on previous experiences and knowledge of the case. However, behavioural attributes, including communication and teamwork, may be expected to be less dependent on specific case knowledge and thus be more stable across cases. This has implications for training and assessment design. In this study we measured the psychometric properties of assessment of behaviour in simulated anaesthetic emergencies.

Twenty anaesthesia trainees were rated in three simulated emergencies by four assessors. The psychometric properties of scores for behaviour were determined and were compared with scores for medical management and overall performance. We found that scores for behaviour were less dependent on the specific clinical context than the scores for overall performance and medical management, implying transferability of crisis management behaviours between cases.
Adverse Physiological Events under Anaesthesia and Sedation: A Pilot Audit of Electronic Patient Records
Authors: Grant C. , Ludbrook G. , Hampson E. A. , Semenov R. , Willis R.
Published: January 2019

Review of perioperative activity, including adverse events, throughput and compliance with ‘best practice’, can theoretically be used to optimise healthcare delivery. Computer-based analysis of electronic patient records could provide a practical means to manage quality improvement. This pilot study examined the effectiveness of such a system in practice.

All intraoperative patient notes and physiological data were collected over 17 months in a rural hospital using data from an electronic record-keeping system. Algorithms were developed to automatically identify potential adverse events based on physiological measures. Each computer-identified event was reviewed by a panel of three anaesthetists and assessed for validity, severity and probable cause. Two areas were identified to pilot quality improvement activities—sedation for colonoscopies and inhalational anaesthesia with desflurane. Specific ‘inhouse’ guidelines were created for these procedures and feedback on the patterns of adverse events were provided to anaesthetic staff.

A total of 138 separate adverse events were identified for all operative cases over 17 months, with an overall adverse event incidence of 3.3%. The adverse event incidence during colonoscopy and laryngospasm/hypoxia during desflurane anaesthesia was 6.3% and 1.3% respectively. This decreased to 2.8% (P <0.005) and 0.13% (P <0.0001) respectively for the nine months following feedback and the introduction of guidelines.

Anaesthesia information systems can be an effective quality improvement tool and may enhance existing tools such as incident reporting systems.
A Series of Five Adult Cases of Respiratory Syncytial Virus-Related Acute Respiratory Distress Syndrome
Authors: Robert D. , Verbiest D. , Demey H. , Ieven M. , Jansens H. , Jorens P. G.
Published: January 2019

Respiratory syncytial virus is a common cause of respiratory tract disease in children, predominantly presenting with mild symptoms. We present five cases of respiratory syncytial virus infection of the lower respiratory tract in immunocompromised adults suffering from severe respiratory insufficiency leading to bilateral pneumonia and fulfilling the criteria for acute respiratory distress syndrome. Respiratory syncytial virus was cultured as the only pathogen in the bronchoalveolar lavage fluid in four of these patients. Despite various therapeutic interventions, only one patient survived. Respiratory syncytial virus was implicated as a direct cause of respiratory failure. Respiratory syncytial virus may be an underestimated cause of severe respiratory failure and acute respiratory distress syndrome in the immunocompromised adult admitted to the intensive care unit.
Anaesthetic Implications of Hyperekplexia—'Startle Disease’
Authors: Garg R. , Ramachandran R. , Sharma P.
Published: January 2019

This report describes anaesthesia for consanguineous siblings with the rare genetic condition hyperekplexia. This condition is also known as ‘stiff baby syndrome’ or ‘startle disease’. Hyperekplexia can present in major and minor forms and is caused by a mutation in chromosome 5 which results in a defect in the α-1 subunit of the inhibitory glycine receptors in the caudal pontine reticular formation leading to neuronal hyperexcitability. The patients present with a potentially life-threatening exaggerated startle reflex. Life-threatening spasms may be terminated by forced flexion of the head and legs towards the trunk. Anaesthesia management should avoid stimuli which trigger the reflex. Clonazepam and diazepam are used to prevent and control the spasms. Propofol and other agents with the ability to potentiate both GABAergic and glycinergic transmission may be appropriate choices for anaesthesia. Reaction to neuromuscular blockers may be unpredictable. Both our patients had relatively prolonged but otherwise uneventful recovery.
An Unusual Case of Intra-Abdominal Apoplexy
Authors: Makris N. , Bellapart J. , Boots R. J.
Published: January 2019

Abdominal apoplexy is an uncommon disorder, typically due to atheromatous vascular disease, inflammatory processes such as pancreatitis eroding into large blood vessels or vasculitis. We describe an unusual case due to unrecognised syphilis masquerading as pancreatitis.