bluuebunny/crossref_metadata_2025 huggingface dataset:
High Frequency Oscillation in the Adult Intensive Care Unit. Nearly Mainstream?
Authors: Corkeron M.
Published: January 2019

High frequency oscillatory ventilation (HFOV) was first described in 1959. It has had variable uptake in critical care with greater use in neonatal and paediatric intensive care units (ICU) than in adults1. In this issue, Boots et al2 describe the use of HFOV across a wide spectrum of patients with severe respiratory failure due to pandemic H1N1 influenza. Units from across Australia and New Zealand contributed data regarding patients admitted during the pandemic. The fact that there is an established network and organisational structure for the study of intensive care outcomes in Australia and New Zealand facilitated the rapid mobilisation of resources to gather data on the intensive care effects of the pandemic, and those involved should be congratulated. Other data on the impact of pandemic H1N1 on Australian ICUs in 2009 have already been published3.
Hypocoagulability, Hypercoagulability and the Interpretation of ‘Normal’ Kaolin-Activated Thrombelastographs in the Perioperative Period
Authors: Gibbs N. M.
Published: January 2019

Kaolin-activated whole blood thrombelastography (TEG) is an appealing test of coagulation in the perioperative period, because it assesses many aspects of coagulation and can be performed at the point of care. In this issue, Weinberg et al report the use of kaolin-activated TEG as a global assessment of coagulation as part of their investigation of coagulation activation after hepatic resection for cancer1. However, while kaolin-activated TEG assesses many aspects of coagulation, it does not assess all aspects of coagulation, so ‘normal’ findings should be interpreted with caution.
The Effect of a Graphical Interpretation of a Statistic Trend Indicator (Trigg's Tracking Variable) on the Detection of Simulated Changes
Authors: Kennedy R. R. , Merry A. F.
Published: January 2019

Anaesthesia involves processing large amounts of information over time. One task of the anaesthetist is to detect substantive changes in physiological variables promptly and reliably. It has been previously demonstrated that a graphical trend display of historical data leads to more rapid detection of such changes. We examined the effect of a graphical indication of the magnitude of Trigg's Tracking Variable, a simple statistically based trend detection algorithm, on the accuracy and latency of the detection of changes in a micro-simulation. Ten anaesthetists each viewed 20 simulations with four variables displayed as the current value with a simple graphical trend display. Values for these variables were generated by a computer model, and updated every second; after a period of stability a change occurred to a new random value at least 10 units from baseline. In 50% of the simulations an indication of the rate of change was given by a five level graphical representation of the value of Trigg's Tracking Variable. Participants were asked to indicate when they thought a change was occurring. Changes were detected 10.9% faster with the trend indicator present (mean 13.1 [SD 3.1] cycles vs 14.6 [SD 3.4] cycles, 95% confidence interval 0.4 to 2.5 cycles, P=0.013. There was no difference in accuracy of detection (median with trend detection 97% [interquartile range 95 to 100%], without trend detection 100% [98 to 100%]), P=0.8. We conclude that simple statistical trend detection may speed detection of changes during routine anaesthesia, even when a graphical trend display is present.
Compliance with Processes of Care in Intensive Care Units in Australia and New Zealand – A Point Prevalence Study
Authors: Hewson-Conroy K. M. , Burrell A. R. , Elliott D. , Webb S. A. R. , Seppelt I. M. , Taylor C. , Glass P.
Published: January 2019

There are indications that compliance with routine clinical practices in intensive care units (ICU) varies widely internationally, but it is currently unknown whether this is the case throughout Australia and New Zealand. A one-day point prevalence study measured the prevalence of routine care processes being delivered in Australian and New Zealand ICUs including the assessment and/or management of: nutrition, pain, sedation, weaning from mechanical ventilation, head of bed elevation, deep venous thrombosis prophylaxis, stress ulcer prophylaxis, blood glucose, pressure areas and bowel action. Using a sample of 50 adult ICUs, prevalence data were collected for 662 patients with a median age of 65 years and a median Acute Physiology and Chronic Health Evaluation II score of 18. Wide variations in compliance were evident in several care components including: assessment of nutritional goals (74%, interquartile range [IQR] 51 to 89%), pain score (35%, IQR 17 to 62%), sedation score (89%, IQR 50 to 100%); care of ventilated patients e.g. head of bed elevation >30 degrees (33%, IQR 7 to 62%) and setting weaning plans (50%, IQR 28 to 78%); pressure area risk assessment (78%, IQR 18 to 100%) and constipation management plan (43%, IQR 6 to 87%). Care components that were delivered more consistently included nutrition delivery (100%, IQR 100 to 100%), deep venous thrombosis (96%, IQR 89 to 100%) and stress ulcer (90%, IQR 78 to 100%) prophylaxis, and checking blood sugar levels (93%, IQR 88 to 100%). This point prevalence study demonstrated variability in the delivery of ‘routine’ cares in Australian and New Zealand ICUs. This may be driven in part by lack of consensus on what is best practice in intensive care units, prompting the need for further research in this area.
Modification of Diamedica Drawover Anaesthetic Equipment to Facilitate Introduction to an Australian Teaching Hospital
Authors: Burstal R. J. , Threlfo S.
Published: January 2019

We wanted to provide training in the use of drawover techniques and apparatus at an Australian teaching hospital. Equipment based on the Diamedica vaporiser was selected as it is suitable for use with sevoflurane. A lack of standards specific to drawover equipment from either anaesthetic professional bodies or national standards authorities hinders introduction of such equipment to Australian hospitals. Two systems were purchased, the Diamedica Portable Anaesthesia System and a Glostavent anaesthetic machine. Changes made to the equipment to increase its safety and to comply with Australian standards are described.
Extracorporeal Membrane Oxygenation in a Patient with Stress-Induced Cardiomyopathy after Caesarean Section
Authors: Jo Y. Y. , Park S. , Choi Y. S.
Published: January 2019

Stress-induced cardiomyopathy is an acute cardiac syndrome mimicking ST-segment elevation myocardial infarction and is characterised by transient left ventricular dysfunction in the absence of obstructive coronary artery disease. Caesarean delivery is associated with intense emotional and physical stress, which may precipitate stress-induced cardiomyopathy mimicking acute myocardial infarction. We report a case of a woman who was supported with extracorporeal membrane oxygenation for acute heart failure and severe pulmonary oedema, which may have resulted from stress-induced cardiomyopathy in the early postpartum period following caesarean delivery.
Computed Tomography Changes of Alveoli and Airway Collapse after Laryngospasm
Authors: Keating M. , Johnson J. , Erb T. O. , von Ungern-Sternberg B. S.
Published: January 2019

An eight-month-old girl underwent a computed axial tomographic study of the chest and neck for investigation of expiratory stridor. Following the scout scan, severe laryngospasm developed. While no cause for the laryngospasm was found, the computed axial tomographic chest study showed marked changes in the lungs consistent with absorption atelectasis which we postulate occurred secondary to laryngospasm.
Benefits and Risks Associated with the R100 High Frequency Oscillatory Ventilator for Patients with Severe Hypoxaemic Respiratory Failure
Authors: Niwa T. , Hasegawa R. , Ryuge M. , Kawase M. , Kondoh Y. , Taniguchi H.
Published: January 2019

High frequency oscillatory ventilation has been shown to improve oxygenation of patients with severe respiratory failure. This prospective study examined the potential benefits and risks of the latest generation high frequency oscillatory ventilator (R100, Metran, Saitama, Japan), initiated when the target oxygenation could not be achieved by conventional mechanical ventilation in adult patients with severe hypoxaemic respiratory failure. Thirty-six patients with severe respiratory failure treated with the R100 high frequency oscillatory ventilator were considered. Pneumonia and exacerbation of interstitial pneumonia were the main causes of respiratory failure. The median time on conventional mechanical ventilation or airway pressure release ventilation prior to high frequency oscillatory ventilation was 9.3 hours (interquartile range 4.8 to 25). PaO2/FiO2 at 24 hours after initiation of high frequency oscillatory ventilation was significantly better than the PaO2/FiO2 at baseline (151.2±61.2 vs 99.5±50.0, P=0.0001). Refractory hypoxaemia within 24 hours was associated with a high risk of mortality (P=0.0092) and 23 patients (64%), including 11 patients with exacerbation of interstitial pneumonia, died by 30 days. Of the 36 patients included in the study (including one who had developed pneumothorax before high frequency oscillatory ventilation), 12 (33%) developed barotrauma during the course of their intensive care unit stay. In the multivariate analysis, only exacerbation of interstitial pneumonia was a significant risk factor for barotrauma. In summary, the latest generation high frequency oscillatory ventilator could improve oxygenation in adult patients with life-threatening hypoxaemic respiratory failure but the incidence of barotrauma was substantial.
Bayesian Statistics: How to Quantify Uncertainty
Authors: McCulloch T. J.
Published: January 2019

In science, as in life, we are continually presented with new evidence that potentially alters our view of reality. We have hypotheses about reality and these hypotheses are subject to adjustment or replacement in the light of new information. However, we are rightly reluctant to discard well-established models of reality every time some new information calls them into question. To do so would place us at the mercy of poorly collected data and chance outliers. New evidence must be weighed against pre-existing evidence and alternative explanations for new data must be considered.
Effect of Statins on the Clinical Outcomes of Patients with Sepsis
Authors: Goodin J. , Manrique C. , Dulohery M. , Sampson J. , Saettele M. , Dabbagh O.
Published: January 2019

Despite numerous attempts at novel intervention and tests to aid in earlier diagnosis and improved treatment, there has been an increased incidence of overall mortality related to sepsis, despite improvements in in-hospital mortality. Statins have emerged as potential immunomodulatory and antioxidant agents that might impact on sepsis outcomes. Definitive evidence to support the routine use of statins in patients with sepsis has not yet been elicited. We retrospectively analysed data from patients who presented with sepsis, severe sepsis or septic shock, stratifiying them according to statin use into two groups (statin and no statin). Sequential Organ Failure Assessment was used to evaluate severity of illness. The primary outcome was hospital mortality. Secondary outcomes included intensive care unit (ICU) mortality, hospital and ICU length of stay, and mechanical ventilation and vasopressor therapy duration. Five hundred and sixty-eight patients were included. Patients with prior statin use (statin group) were older, more obese and had higher prevalence of smoking, diabetes and ischaemic heart disease. There was no difference in Sequential Organ Failure Assessment scores and mortality did not vary between the two groups (19.6 vs 16.9%). Furthermore, secondary outcomes including ICU mortality, hospital and ICU length of stay, mechanical ventilation and vasopressor duration did not differ. Multivariate analysis revealed age and Sequential Organ Failure Assessment score were independent predictors of survival, while history of statin use was not (P=0.403). This current retrospective study did not find any benefit of statin use on primary and secondary outcomes of the patients admitted to an academic hospital with sepsis.
Jet Ventilation for the Excision of Vocal Cord Polyps in a Pregnant Patient
Authors: Shobary H. EL , Gauthier M. , Schricker T.
Published: January 2019

The anaesthetic management of patients presenting with laryngeal tumours and airway obstruction is difficult. We present the case of a pregnant woman at 30 weeks gestation who underwent surgical removal of two vocal cord polyps under general anaesthesia using jet ventilation
The Role of Regional Anaesthesia Techniques in the Management of Acute Pain
Authors: Cowlishaw P. J. , Scott D. M. , Barrington M. J.
Published: January 2019

Regional anaesthesia and analgesia techniques are used to effectively manage acute pain after a variety of surgeries. With the rapid growth of ultrasound-guided procedures, anaesthetists are re-examining regional anaesthesia and analgesia and their roles in pain management. In this evolving field previous published data may not reflect current practice. Therefore, a narrative review of recent literature was undertaken to establish the current utility and efficacy of regional anaesthesia and analgesia for the management of acute pain following surgery. Only prospective randomised controlled trials published between March 2009 and March 2011 with outcome measures of analgesia efficacy were included. Sixty-five randomised controlled trials were identified involving 4841 patients. Regional techniques for the management of knee (26%), abdominal (26%) and shoulder (14%) surgery were most frequently studied. The review provides further evidence that regional anaesthesia and analgesia can offer excellent analgesia with acceptable side-effects for the management of post surgical pain. In addition, the results of this review support the use of ultrasound guidance when performing regional techniques and continuous catheter techniques to prolong analgesia.
Comparison of Haemodynamic Responses following Different Concentrations of Adrenaline with and without Lignocaine for Surgical Field Infiltration during Cleft Lip and Cleft Palate Surgery in Children
Authors: Muthukumar M. , Arya V. K. , Mathew P. J. , Sharma R. K.
Published: January 2019

Surgical field infiltration with adrenaline is common practice for quality surgical field during cleft lip and palate repair in children. Intravascular absorption of adrenaline infiltration often leads to adverse haemodynamic responses. In this prospective, double-blinded, randomised study the haemodynamic effects, quality of surgical field and postoperative analgesia following surgical field infiltration with different concentrations of adrenaline with and without lignocaine were compared in 100 American Society of Anesthesiologists physical status I children aged six months to seven years undergoing cleft lip/palate surgery. A standard anaesthesia protocol was used and they were randomised into four groups based on solution for infiltration: adrenaline 1:400000 (group A), adrenaline 1:200,000 (group B), lignocaine + adrenaline 1:400,000 (group C) and lignocaine + adrenaline 1:200,000 (group D). Statistically significant tachycardia and hypertension occurred only in group B as compared to other groups (P <0.001). The peak changes in heart rate and mean arterial pressure following infiltration occurred at 4.3±2.4, 3.8±1.5, 5.7±3.2 and 5.9±4.9 minutes in groups A, B, C and D respectively. Surgical field was comparable among all groups. Postoperative pain scores and rescue analgesic requirements were lesser in the groups where lignocaine was added to the infiltrating solution (P <0.05). We found that 1:400000 or 1:200000 adrenaline with lignocaine 0.5 to 0.7% is most suitable for infiltration in terms of stable haemodynamics, quality of surgical field and good postoperative analgesia in children.
Improving the C-MAC Video Laryngoscopic view when Applying Cricoid Pressure by allowing access of Assistant to the Video Screen
Authors: Loughnan T. E. , Gunasekera E. , Tan T. P.
Published: January 2019

Cricoid pressure, as part of rapid sequence induction, may on occasion worsen laryngoscopic views and intubating conditions. We investigated whether allowing the assistant applying cricoid pressure to view the video laryngoscope screen would improve the laryngoscopic views compared to when they were blinded to the video screen. Laryngoscopy using the C-MAC video laryngoscope was performed in 51 patients undergoing elective general anaesthesia. Photographs were recorded sequentially under the following conditions: A) cricoid pressure by an assistant unable to see the video monitor, and B) cricoid pressure optimised by an assistant able to see the video monitor. These photographs were analysed offline by assessors blinded to whether the photo was obtained with blinded or non-blinded cricoid pressure application. Subjectively, 41% of views were improved when the assistant applying cricoid pressure was able to see the C-MAC screen, compared to those unable to see the screen. The view was unchanged in 45%, but initially worsened in 14%. These findings suggest that assistants applying cricoid pressure when a C-MAC is used should have access to the video image, but must also respond to requests for change from the person performing the intubation.
Audit of Extrapleural Local Anaesthetic Infusion in Neonates following Repair of Tracheo-Oesophageal Fistulae and Oesophageal Atresia via Thoracotomy
Authors: Palmer G. M. , Thalayasingam P. , Mcnally C. M. , Tingay D. G. , Smith K. R. , Clarnette T. D. , Penrose S. , Dowden S. J. , Chalkiadis G. A.
Published: January 2019

In order to reduce postoperative opioid requirement, extrapleural local anaesthetic infusion dosing recommendations and guidelines for extrapleural catheter insertion were developed in our institution for ‘extubatable’ neonates requiring short-gap neonatal tracheo-oesophageal fistula/oesophageal atresia repair (via thoracotomy) and audited prospectively. Data audited included patient characteristics, analgesia details and ventilation duration. We divided patients into two groups: group 1 – term patients (>36 weeks gestational age) with birth-weights >2.5 kg; group 2 – pre-term patients (<36 weeks gestational age), with birth weights <2.5 kg and those with co-morbidities. There were 26 neonates in group 1 and 11 in group 2. All received extrapleural infusions of bupivacaine or levobupivacaine: the majority (90%) <300 μg.kg−1.hour−1 (median duration 43 hours, range 1.5 to 72 hours); 36% required morphine infusion and 39% were ventilated (median duration 34 hours, range 3 to 140 hours). In group 1, 24% required morphine infusion compared with 64% in group 2. Most group 1 patients (77%) were extubated immediately postoperatively; 20% had short duration ventilation (median 15 hours, range 11 to 37 hours); one required longer-term ventilation (231 hours). 82% of group 2 were ventilated for a median of 72 hours (range 3 to 140 hours). Review of patients’ co-morbidities facilitated guideline revision. These now specify use in neonates requiring short-gap tracheo-oesophageal fistula/oesophageal atresia repair who are term at >36 weeks gestational age and >2.5 kg birth-weight, anticipated as ready for extubation either immediately or shortly after surgery.
Ketofol (Mixture of Ketamine and Propofol) Administration in Electroconvulsive Therapy
Authors: Kayhan G. Erdogan , Yucel A. , Colak Y. Z. , Ozgul U. , Yologlu S. , Karlidag R. , Ersoy M. O.
Published: January 2019

The aim of this study was to evaluate the effect of a ketamine:propofol combination (‘ketofol’) for electroconvulsive therapy on seizure activity, haemodynamic response and recovery parameters, and to compare with these with the effects of propofol alone. Twenty-four patients underwent a total of 144 electro-convulsive therapy sessions, allocated in this prospective, double-blind, crossover study. Patients were randomly assigned to receive 1 mg/kg ketofol (0.5 mg/kg propofol plus 0.5 mg/kg ketamine) or 1 mg/kg propofol 1% for anaesthesia induction. Seizure duration and quality, haemodynamic data, recovery parameters and side-effects were recorded and analysed between groups. Both motor and electroencephalography seizure durations in the ketofol group (29±17 and 41±17 seconds, respectively) were similar to that in the propofol group (28±13 and 38±16 seconds, respectively). Postictal suppression index was higher in the ketofol group (89.63±7.88) than in the propofol group (79.74±14.6) (P P <0.05). There were no untoward psychological reactions following ketofol. Although no superiority to propofol in terms of seizure duration, haemodynamic or recovery parameters was found, the ketofol mixture selected in our study provided better seizure quality than propofol. We conclude that ketofol can be an alternative strategy to enhance the seizure quality and clinical efficiency of electroconvulsive therapy.
Rural Anaesthetic Audit 2006 to 2010
Authors: Mills P. D. , Newbury J.
Published: January 2019

In order to review anaesthetic morbidity in our remote rural hospital, a retrospective audit of all anaesthetic records was undertaken for a five-year period between 2006 and 2010. Eight hundred and eighty-nine anaesthetic records were reviewed. The patients were all American Society of Anaesthesiologists physical status I to III. Ninety-eight percent of the anaesthetics were performed by general practitioner (non-specialist) anaesthetists. There were no anaesthetic deaths or serious adverse outcomes reported over this period. Sixteen intraoperative and seven postoperative problems were documented, but all were resolved uneventfully. The most common problems documented were difficult intubation (n=9) and respiratory depression (n=3). Within the limitations of this retrospective audit, these findings indicate that general practitioner anaesthetists provided safe anaesthesia in a remote rural hospital. It is our opinion that the case selection, prior experience of anaesthetic and theatre staff, stable nursing workforce and the use of protocols were important factors in determining the low rate of adverse events. However, we caution against over-interpretation of the data, given its retrospective nature, relatively small sample size, reliance on case records and the absence of agreed definitions for adverse events. We would also like to encourage all anaesthetic services, however remote, to audit their results as part of ongoing quality assurance.
The PiCCO Monitor: A Review
Authors: Litton* E. , Morgan M.
Published: January 2019

Advanced haemodynamic monitoring remains a cornerstone in the management of the critically ill. While rates of pulmonary artery catheter use have been declining, there has been an increase in the number of alternatives for monitoring cardiac output as well as greater understanding of the methods and criteria with which to compare devices. The PiCCO (Pulse index Continuous Cardiac Output) device is one such alternative, integrating a wide array of both static and dynamic haemodynamic data through a combination of trans-cardiopulmonary thermodilution and pulse contour analysis. The requirement for intra-arterial and central venous catheterisation limits the use of PiCCO to those with evolving critical illness or at high risk of complex and severe haemodynamic derangement. While the accuracy of trans-cardiopulmonary thermodilution as a measure of cardiac output is well established, several other PiCCO measurements require further validation within the context of their intended clinical use. As with all advanced haemodynamic monitoring systems, efficacy in improving patient-centred outcomes has yet to be conclusively demonstrated. The challenge with PiCCO is in improving the understanding of the many variables that can be measured and integrating those that are clinically relevant and adequately validated with appropriate therapeutic interventions.
Accuracy of ProSeal™ Laryngeal Mask Airway Intracuff Pressure Estimation using Finger Palpation technique – A Prospective, Observational Study
Authors: Teoh P. F. , Seet E. , Macachor J. , Chia N.
Published: January 2019

The incidence of pharyngolaryngeal adverse events associated with laryngeal mask airways can be reduced by the use of manometry to limit the laryngeal mask airway intracuff pressures. We conducted a prospective, observational study in 80 patients undergoing general anaesthesia with the ProSeal™ laryngeal mask airway to determine the accuracy of a finger palpation technique compared to actual readings obtained from a handheld manometer by different anaesthesia personnel. The strength of association of estimated versus actual intracuff pressures, R, for nurse anaesthesia assistants, junior anaesthetists and senior anaesthetists were 0.21 (weak), 0.35 (moderate) and 0.78 (strong) respectively. Subgroup analysis showed that anaesthetists with more than three years of experience were more accurate than those with less than three years of experience. The actual versus estimated intracuff pressures were 4±17 vs 19±27 cmH2O ( P value <0.001) respectively. In all groups, the palpation technique tended to underestimate the actual intracuff pressure by a mean of 10.3 cmH2O. Palpation accuracy decreased when actual intracuff pressures were >80 cmH2O. These findings suggest that cuff pressure manometry should be recommended as standard of care with the use of laryngeal mask airways.
In Vitro Thrombotic Tendency of Reactive Thrombocytosis in Critically Ill Patients: A Prospective Case-control Study
Authors: Duff* O. C. , Ho K. M. , Maybury S. M.
Published: January 2019

It is uncertain whether reactive thrombocytosis is associated with an increased risk of thrombosis. This prospective case-control study assessed the in vitro thrombotic tendency of patients with reactive thrombocytosis. Forty-eight patients with reactive thrombocytosis, defined by platelet count >500×109/l and 55 similar, randomly selected critically ill patients who did not have reactive thrombocytosis were considered. In vitro thrombotic tendency in both groups of patients was assessed using the maximal amplitude (normal range 54 to 72 mm) and alpha angle (normal range 47 to 74°) on the thromboelastograph. The associations between reactive thrombocytosis and C-reactive protein, the coagulation profile and Sequential Organ Failure Assessment score were also evaluated. Patients with reactive thrombocytosis had an associated increased in vitro thrombotic tendency (maximal amplitude 77 vs 69 mm, mean difference 8 mm, 95% confidence interval 4.9 to 10.9, P=0.001), a higher fibrinogen concentration (7.2 vs 5.8 g/l, P=0.003), and a higher incidence of infection requiring antibiotics (50 vs 27%, P=0.025) compared to patients without thrombocytosis. Platelet count had a relatively linear relationship with the maximal amplitude and the alpha angle of the thrombo-elastograph tracing (Pearson correlation coefficient: 0.53, P=0.001). In the multivariate analysis, only reactive thrombocytosis (odds ratio 5.9, 95% confidence interval 1.3 to 27.8, P=0.025) and activated partial thromboplastin time (odds ratio 0.93 per second increment, 95% confidence interval 0.87 to 0.99, P=0.016) were significantly associated with a strong in vitro thrombotic tendency. In summary, reactive thrombocytosis was associated with infection requiring antibiotics and evidence of increased in vitro thrombotic tendency in critically ill patients.
Dreaming during Sevoflurane or Propofol Short-Term Sedation: A Randomised Controlled Trial
Authors: Xu G. H. , Liu X. S. , Yu F. Q. , Gu E. W. , Zhang J. , Wang K.
Published: January 2019

Prior reports suggest that dreaming during anaesthesia is dependent on recovery time. Dreaming during sedation may impact patient satisfaction. The current study explores the incidence and content of dreaming during short-term sedation with sevoflurane or propofol and investigates whether dreaming is affected by recovery time. A total of 200 women undergoing first trimester abortion (American Society of Anesthesiologists physical status I) participated in the study. Patients were randomly assigned to receive either sevoflurane or propofol for short-term sedation. Patients were interviewed upon emergence with the modified Brice questionnaire. The results showed the incidence of dreaming was significantly different between anaesthesia groups with 60% (60/100) of the sevoflurane group and 33% (33/100) of the propofol group ( P=0.000). However, recovery time did not significantly differ between groups. In the sevoflurane group, a greater number of dreamers could not recall what they had dreamed about ( P=0.02) and more patients reported dreams that had no sound ( P=0.03) or movement ( P=0.001) compared with dreamers in the propofol group. Most participants reported dreams with positive emotional content and this did not significantly differ between groups. Anaesthesia administered had no effect on patient satisfaction. The results suggest that the incidence of dreaming was not affected by recovery time. Patient satisfaction was not influenced by choice of sedative and/or by the occurrence of dreaming during sevoflurane or propofol short-term sedation.
Analysis of the Entire Ryanodine Receptor type 1 and Alpha 1 Subunit of the Dihydropyridine Receptor (CACNA1S) Coding Regions for Variants Associated with Malignant Hyperthermia in Australian Families
Authors: Gillies R. L. , Bjorksten A. R. , Du Sart D. , Hockey B. M.
Published: January 2019

Defects in the genes coding for the skeletal muscle ryanodine receptor (RYR1) and alpha 1 subunit of the dihydropyridine receptor (CACNA1S) have been identified as causative for malignant hyperthermia (MH). Sixty-two MH susceptible individuals presenting to the same diagnostic centre had copy deoxyribonucleic acid, derived from muscle ribonucleic acid, sequenced to identify variants with the potential to be responsible for the MH phenotype in both RYR1 and CACNA1S. These genetic findings were combined with clinical episode details and in vitro contracture test results to improve our understanding of the Australian MH cohort. Twelve novel variants were identified in RYR1 and six in CACNA1S. Known RYR1 causative mutations were identified in six persons and novel variants in RYR1 and CACNA1S in a further 17 persons. Trends indicated higher mutation identification in those with more definitive clinical episodes and stronger in vitro contracture test responses.
The Epidemiology of Sepsis during Rapid Response Team Reviews in a Teaching Hospital
Authors: Cross G. , Bilgrami I. , Eastwood G. , Johnson P. , Howden B. P. , Bellomo R. , Jones D.
Published: January 2019

In a three-month retrospective study, we assessed the proportion of rapid response team (RRT) calls associated with systemic inflammatory response syndrome (SIRS) and sepsis. We also documented the site of infection (whether it was community- or hospital-acquired), antibiotic modifications after the call and in-hospital outcomes. Amongst 358 RRT calls, two or more SIRS criteria were present in 277 (77.4%). Amongst the 277 RRT calls with SIRS criteria, 159 (57.4%) fulfilled sepsis criteria in the 24 hours before and 12 hours after the call. There were 118 of 277 (42.6%) calls with SIRS criteria but no evidence of sepsis and 62 of 277 (22.3%) calls associated with both criteria for sepsis as well as an alternative cause for SIRS. Hence, 159 (44.4%) of all 358 RRT calls over the three-month study period fulfilled criteria for sepsis and in 97 (159–62) (27.1%) of the 358 calls, there were criteria for sepsis without other causes for SIRS criteria. The most common sites of infection were respiratory tract (86), abdominal cavity (38), urinary tract (26) and bloodstream (26). Infection was hospital-acquired in 91 (57.2%) and community-acquired in 67 (42.1%) cases, respectively. Patients were on antibiotics in 127 of 159 (79.9%) cases before the RRT call and antibiotics were added or modified in 76 of 159 (47.8%) cases after RRT review. The hospital length-of-stay of patients who received an RRT call associated with sepsis was longer than those who did not (16.0 [8.0 to 28.5] versus 10 [6.0 to 18.0]; P=0.002).
Measuring the Clinical Learning Environment in Anaesthesia
Authors: Smith N. A. , Castanelli D. J.
Published: January 2019

The learning environment describes the way that trainees perceive the culture of their workplace. We audited the learning environment for trainees throughout Australia and New Zealand in the early stages of curriculum reform. A questionnaire was developed and sent electronically to a large random sample of Australian and New Zealand College of Anaesthetists trainees, with a 26% final response rate. This new instrument demonstrated good psychometric properties, with Cronbach's α ranging from 0.81 to 0.91 for each domain. The median score was equivalent to 78%, with the majority of trainees giving scores in the medium range. Introductory respondents scored their learning environment more highly than all other levels of respondents ( P=0.001 for almost all comparisons). We present a simple questionnaire instrument that can be used to determine characteristics of the anaesthesia learning environment. The instrument can be used to help assess curricular change over time, alignment of the formal and informal curricula and strengths and weaknesses of individual departments.
A Comparison of Outcomes among Hospital Survivors with and without Severe Comorbidity Admitted to the Intensive Care Unit
Authors: Williams T. A. , Mcconigley R. , Leslie G. D. , Dobb G. J. , Phillips M. , Davies H. , Aoun S.
Published: January 2019

Little is known about the experiences of patients with severe comorbidity discharged from Intensive Care Units (ICUs). This project aimed to determine the effects of an ICU stay for patients with severe comorbidity by comparing 1) quality of life (QOL), 2) the symptom profile of hospital survivors and 3) health service use after hospital discharge for patients admitted to ICU with and without severe comorbidity. A case-control study was used. Patients with severe comorbidity were matched to a contemporaneous cohort of ICU patients by age and severity of illness. Assessment tools were the Medical Outcome Study 36-item short-form and European Organisation for Research and Treatment of Cancer QLQ-C15-PAL questionnaires for QOL and the Symptom Assessment Scale for symptom distress. A proportional odds assumption was performed using an ordinal regression model. The difference in QOL outcome was the dependent variable for each pair. Health service use after discharge from ICU was monitored with patient diaries. Patients aged 18+ years admitted to an ICU in a metropolitan teaching hospital between 2011 and 2012 were included. We recruited 30 cases and 30 controls. QOL improved over the six months after hospital discharge for patients with and without severe comorbidity ( P <0.01) within the groups but there was no difference found between the groups ( P >0.3). There was no difference in symptoms or health service use between patients with and without severe comorbidity. ICU admission for people with severe comorbidity can be appropriate to stabilise the patient's condition and is likely to be followed by some overall improvement over the six months after hospital discharge.
Maternal Pulmonary Oedema during Foetoscopic Surgery
Authors: Katz S. G. , Somerville K. P. , Welsh A.
Published: January 2019

We report a case of maternal pulmonary oedema necessitating intubation and ventilation with associated hyperchloraemic metabolic acidosis during foetoscopic laser surgery for twin-twin transfusion syndrome (TTTS), believed to be secondary to absorption of normal saline irrigation fluid. TTTS complicates 10% to 20% of monochorionic twin pregnancies and develops due to imbalanced vascular anastomoses and consequent unidirectional transfusion between the twins. The recipient is at risk of cardiac failure due to circulatory overload and the donor twin becomes hypoperfused. The recipient is polyhydramniotic and the donor is oligohydramniotic. Untreated severe TTTS has a mortality rate of up to 90%. Treatment options include delivery if viable, serial amnioreduction or foetoscopic laser ablation of the communicating vessels. Since the Eurofoetus study, laser ablation has been the mainstay of treatment for pre-viable TTTS, involving insertion of endoscopes transabdominally into the polyhydramniotic sac to allow visualisation and ablation of the anastosmotic vessels. Amnioreduction does not correct the underlying pathology and offers very little in advanced disease. Foetoscopic laser ablation leads to an improved survival past 28 days and a lower incidence of neurological complications compared to serial amnioreduction.
Obesity Prevalence and Associated Outcomes in Cardiothoracic Patients: A Single-Centre Experience
Authors: Goh R. , Darvall J. , Wynne R. , Tatoulis J.
Published: January 2019

The objective of this study was to investigate the prevalence of obesity and its relationship with adverse outcomes in ICU cardiothoracic patients. We performed a retrospective analysis of cardiothoracic patients admitted to The Royal Melbourne Hospital ICU between 2002 and 2014. Eight thousand and sixty-four patients who underwent coronary artery bypass, valve replacement/repair, or both, were divided into six categories of body mass index using World Health Organization criteria. Prevalence of obesity over time in the ICU was measured and compared to prevalence of obesity in the adult Australian population. The association between obesity and adverse postoperative outcomes was then analysed. Obesity is currently 1.2 times more prevalent in the Royal Melbourne Hospital ICU cardiothoracic patients than in the adult Australian population, with 33.5% of patients having a body mass index ≥30 kg/m2. Over time, this was relatively constant, but an increasing proportion were morbidly obese. Obesity, but not morbid obesity, was associated with reduced 30-day mortality (odds ratio [OR] 0.41). Both obese and morbidly obese patients had reduced odds of return to theatre for bleeding (OR 0.49 and OR 0.19, respectively), but increased odds of new-onset renal failure (OR 1.62 and OR 3.17, respectively). Morbidly obese patients had double the odds of an ICU stay longer than 14 days (OR 2.05). In summary, a growing proportion of our obese ICU patients are morbidly obese, with a dramatically increased length of ICU stay. This has major implications for resource allocation in the ICU, and may inform modelling of future bed utilisation. Obesity, but not morbid obesity, conferred a mortality benefit.
Potential Donor Families' Experiences of Organ and Tissue Donation–related Communication, Processes and Outcomes
Authors: Marck C. H. , Neate S. L. , Skinner M. , Dwyer B. , Hickey B. B. , Radford S. T. , Weiland T. J. , Jelinek G. A.
Published: January 2019

We aimed to describe the experiences of families of potential organ and tissue donors eligible for donation after circulatory death or brain death. Forty-nine family members of potential donors from four Melbourne hospitals were interviewed to assess their experiences of communication, processes and the outcomes of donation. Interviews were recorded, transcribed verbatim and analysed thematically. Families expressed a range of perspectives on the themes of communication, hospital processes and care, the processes of consent and donation and reflected on decisions and outcomes. They expressed satisfaction overall with communication when receiving bad news, discussing death and donation. Honest and frank communication and being kept up-to-date and prepared for potential outcomes were important aspects for families, especially those of post circulatory death donors. Participants reported high levels of trust in healthcare professionals and satisfaction with the level of care received. Many donor families indicated the process was lengthy and stressful, but not significantly enough to adversely affect their satisfaction with the outcome. Both the decision itself and knowing others' lives had been saved provided them with consolation. No consenting families, and only some non-consenting families, regretted their decisions. Many expressed they would benefit from a follow-up opportunity to ask questions and clarify possible misunderstandings. Overall, while experiences varied, Australian families valued frank communication, trusted health professionals, were satisfied with the care their family member received and with donation processes, despite some apparent difficulties. Family satisfaction, infrequently assessed, is an important outcome and these findings may assist education for Australian organ donation professionals.
Prolonged Fasting of Children before Anaesthesia is Common in Private Practice
Authors: Buller Y. , Sims C.
Published: January 2019

Fasting guidelines for children are well established. Despite these guidelines, previous studies have shown children are often fasted for prolonged periods before anaesthesia, potentially causing discomfort and distress. Moreover, recent publications indicate shorter fasting times for oral clear fluids in children may be safe. We audited fasting times of children having elective surgery at a local large private hospital that provides care for both adults and children. We gave feedback and education to our caregivers, then repeated the audit. Data were collected from 307 children (age 6.0 ± 4.1 years) in an initial eight-week audit, and from 153 children (age 6.7 ± 4.5 years) in a follow-up four-week audit. We found fasting durations were excessive in many children. Sixty-two percent of children in each audit fasted longer than four hours for clear fluids. Children on morning lists fasted longer than children on afternoon lists. Fasting from solids was also excessively long. In the initial audit, 30% fasted more than 12 hours for solids, including 18 who last ate more than 16 hours before surgery. Data from the follow-up audit were similar. We conclude that fasting of children at our hospital is excessive, despite our efforts to shorten the duration. We suspect that our hospital is not the only one with a high incidence of prolonged fasting for children and suggest possible solutions.
Intentions and Barriers to Research Activities among Australian and New Zealand anaesthetists: A Survey
Authors: Gurunathan U. , Berry K. , Way M.
Published: January 2019

A voluntary, anonymous, cross-sectional online survey was conducted among 997 Fellows of the Australian and New Zealand College of Anaesthetists, using an electronic questionnaire. Details about their demographics, employment, research experience and barriers they had encountered, their perception about research and their future intentions to participate in research, were collected. The survey response rate was 24.6%. At the time of the survey, 29% of the survey respondents were involved in research. Respondents currently involved in research were more likely to be practising at a tertiary hospital, to have previously presented at conferences, to believe in the importance of research and to intend to undertake further research training ( P <0.05). Time constraints were the most commonly cited reason for not currently performing research. Those who were involved in research spent about 6.3 more hours per week in public practice than those who were not ( P=0.012) and had about 4.4 more hours per week of non-clinical time ( P <0.001). In terms of barriers encountered during previous projects, 91% of the respondents cited methodological issues, which included complicated ethics approval processes, difficulty in coordinating teams or recruiting participants, non-compliant patients and difficulty in publishing. Sixty-three percent of those surveyed believed more exposure to research activities during training would increase the number of anaesthetists involved in research and scholarly activities. Through this survey, we have identified several areas that, if satisfactorily addressed, could enhance interest and participation in research amongst anaesthetists in Australia and New Zealand.
Automated external defibrillator use for in-hospital emergency management
Authors: Huschak G. , Dünnebier A. , Kaisers U. X. , Bercker S.
Published: January 2019

The in-hospital spread of automated external defibrillators (AEDs) is aimed to allow for a shock-delivery within three minutes. However, it has to be questioned if the implementation of AED alone really contributes to a ‘heart-safe hospital’.

Methods

Cohort study of 1008 in-hospital emergency calls in a university tertiary care hospital. Analysis of cardio-pulmonary resuscitation (CPR) cases with and without AED use.

Results

A number of 484 patients (48%) had cardiac arrest and received CPR. Response time of the emergency team was 4.3 ± 4.0 minutes. 8% percent of the CPR cases had a shockable rhythm. In only three cases of 43 placements a shock was delivered by the AED. There were no differences in survival between patients with CPR only and CPR with AED use.

Conclusion

Our data do not support the use of an AED for in-hospital CPR if a professional response team is rapidly available.
Intensive Care Management of Children Intubated for Croup: A Retrospective Analysis
Authors: Gelbart B. , Parsons S. , Sarpal A. , Ninova P. , Butt W.
Published: January 2019

Croup remains the commonest reason for acute upper airway obstruction in children, yet there are scarce contemporary data of airway management in those requiring intubation. We performed a retrospective analysis of the intensive care management of children intubated for croup in two quaternary paediatric intensive care units: Royal Children's Hospital Melbourne, Australia, and Alberta Children's Hospital, Calgary, Canada. Patients intubated for less than three days were compared with those intubated for greater than three days. Patients less than 10 kg body weight were compared to those greater than 10 kg. Demographic, clinical and microbiological data were recorded. Seventy-seven cases of croup requiring intubation were identified. The median duration of intubation was 60 hours. Parainfluenza was the most common viral aetiology, detected in 30% of cases. Antibiotics were prescribed in 51% of patients. Corticosteroids were prescribed pre-intubation in two-thirds of patients and all post-intubation, with the median dose being prednisolone 3 mg/kg/day. Primary extubation failure occurred in 6.5% of patients. Neither the duration of intubation nor patient size were associated with extubation failure. An air leak test was performed in 69% of patients and poorly predicted extubation success. One non-urgent tracheostomy was performed and there was one death from hypoxic ischaemic encephalopathy. Endotracheal tube leak is poorly recorded and may not predict successful extubation.