bluuebunny/crossref_metadata_2025 huggingface dataset:
Recombinant Activated Factor VII for Exsanguinating Haemorrhage Post Bilateral Lung Transplantation for Extra-corporeal Lung Support-dependent Respiratory Failure
Authors: Lucey M. A. , Myburgh J. A.
Published: January 2019

Following three weeks of extracorporeal lung support for acute respiratory distress syndrome, a 15-year-old male underwent bilateral lung transplantation. This procedure was complicated by massive postoperative haemorrhage. The administration of recombinant activated Factor VII was associated with improved haemostasis. However, development of cardiac tamponade soon after injection required emergency exploration and evacuation of a large mediastinal clot.
Preoperative Use of Herbal Medicines and Vitamin Supplements
Authors: Grauer R. P. , Thomas R. D. , Tronson M. D. , Heard G. C. , Diacon M.
Published: January 2019

There has been a definite increase in the popularity and use of complementary and alternative medicines, including herbal medicines, in the last ten years. The aim of this study was to determine the prevalence and patterns of use of herbal medicines and vitamin supplements by patients in the preoperative period. A questionnaire was offered to all patients attending the pre-admission clinics at St. Vincent's Hospital and Box Hill Hospital, Melbourne, over an eight-month period in 2002.

In all, 1102 questionnaires were completed (91.8% response rate). The prevalence of herbal medicine use was 14.3%, with an average user age of 54.0 years and 61.4% female predominance. The five most popular herbs were Garlic, Evening Primrose, Gingko, St. John's Wort and Echinacea. The commonest reasons for herbal medicine use were acute and chronic medical conditions. 63.2% of patients had self-prescribed. 27.8% of herbal remedy users had informed the hospital doctors and 41.8% had notified their general practitioner. The prevalence of vitamin supplement use was 20.4%, with an average user age of 54.8 years and 66.2% female predominance. The five most popular vitamins were multivitamins, followed by vitamin B, C, E and D. The commonest reasons for vitamin use were maintenance of general well-being and health.

The use of herbal medicines and vitamin supplements preoperatively by patients is common. Clinicians should endeavour to familiarize themselves with the more popular and significant herbal medications and, as part of the routine preoperative assessment, ask all their patients about their consumption of herbal remedies.
Anatomy and Anaesthesia of the Lumbar Somatic Plexus
Authors: Sim I. W. , Webb T.
Published: January 2019

Cadaveric dissection demonstrated the lumbar plexus to lie within the substance of psoas major, with the major branches of the lumbar plexus emerging into the psoas compartment adjacent to the L5 vertebra. Within psoas major, the lateral femoral cutaneous and femoral nerves were separated from the obturator nerve by a muscular fold in 36 of 60 plexuses. Anatomical variations were common, with the accessory obturator nerve being identified in 12 per cent of plexuses. All previously described lumbar plexus block approaches positioned the needle within close proximity to the lumbar plexus. Modifications to these approaches may increase efficacy and reduce complication rates.
A Comparison of Open and Laparoscopic Approaches to Adrenalectomy in Patients with Phaeochromocytoma
Authors: Davies M. J. , McGlade D. P. , Banting S. W.
Published: January 2019

We compared the perioperative profiles of patients undergoing unilateral phaeochromocytoma resection performed by open adrenalectomy with those performed by laparoscopic adrenalectomy.

Data was collected prospectively on 24 patients (12 open, 12 laparoscopic). All patients underwent extensive preoperative medical preparation with phenoxybenzamine and β-blockers. The final preoperative dose of phenoxy-benzamine was similar in each group (laparoscopic 119±60 mg/day, open 100±25 mg/day).

Intraoperative haemodynamic instability was assessed by the requirement for therapeutic intervention. More haemodynamic instability was observed in the laparoscopic group but the differences were not statistically significant. Sodium nitroprusside use to treat hypertension (systolic blood pressure >180 mmHg) was more frequent and the duration of the infusions longer in the laparoscopic group; high dose β-blocker therapy with atenolol and/or esmolol to treat intraoperative tachycardia (heart rate >90) was also more frequent in the laparoscopic group. The small sample size of the study limited the ability to detect a true difference. Blood loss was greater in the open adrenalectomy group but the difference was not significant. The operating time was significantly longer (236±78 vs 147±47 min, P<0.01) but the duration of postoperative hospitalization was significantly shorter (5±2 vs 11±4 days, P<0.01) in the laparoscopic group. Postoperative complications were not significantly different. There were no perioperative deaths.

Overall, we observed more haemodynamic instability in patients undergoing laparoscopic resection but were unable to demonstrate a statistically significant difference. In our experience, laparoscopic adrenalectomy has the advantage of a shorter time to discharge from hospital.
Anaesthesia for Electroconvulsive Therapy: A Comparison of Sevoflurane with Propofol
Authors: Hodgson R. E. , Dawson P. , Hold A. R. , Rout C. C. , Zuma K.
Published: January 2019

This study was a prospective audit of patients receiving either intravenous induction of anaesthesia with propofol 2 mg/kg or inhalational induction using 8% sevoflurane for patients undergoing electroconvulsive therapy (ECT). All patients received inhaled 50% nitrous oxide. The anaesthetic agent was determined by psychiatrist preference. Each psychiatrist nominated only one induction technique for all his or her patients. Seventy treatments were studied in each group. Induction time was longer in the sevoflurane group. The time from commencing induction to loss of verbal contact was [mean (SD)] 64 (29.9) seconds for sevoflurane and 36 (33.6) seconds for propofol (P=0.001). Time to loss of eyelash reflex was 82 (32.6)s for sevoflurane and 44 (17.9)s for propofol (P<0.001). The duration of seizure activity was longer in sevoflurane patients, 35 (17.8)s, compared with 20 (9.8)s in the propofol group (P< 0.001). Discharge times were similar. Minor adverse effects occurred in three patients, all in the sevoflurane group (one bradycardia and two episodes of post-procedural nausea). There were no major adverse events in either group. Propofol and sevoflurane both appear to be suitable agents for induction of anaesthesia for ECT.
Predictors of Physician Confidence to Diagnose Pneumonia and Determine Illness Severity in Ventilated Patients. Australian and New Zealand Practice in Intensive Care (ANZPIC II)
Authors: Boots R. J. , Lipman J. , Bellomo R. , Stephens D. , Heller R. F.
Published: January 2019

The manner in which elements of clinical history, physical examination and investigations influence subjectively assessed illness severity and outcome prediction is poorly understood. This study investigates the relationship between clinician and objectively assessed illness severity and the factors influencing clinician's diagnostic confidence and illness severity rating for ventilated patients with suspected pneumonia in the intensive care unit (ICU).

A prospective study of fourteen ICUs included all ventilated admissions with a clinical diagnosis of pneumonia. Data collection included pneumonia type – community-acquired (CAP), hospital-acquired (HAP) and ventilator-associated (VAP), clinician determined illness severity (CDIS), diagnostic methods, clinical diagnostic confidence (CDC), microbiological isolates and antibiotic use.

For 476 episodes of pneumonia (48% CAP, 24% HAP, 28% VAP), CDC was greatest for CAP (64% CAP, 50% HAP and 49% VAP, P<0.01) or when pneumonia was considered “life-threatening” (84% high CDC, 13% medium CDC and 3% low CDC, P<0.001). “Life-threatening” pneumonia was predicted by worsening gas exchange (OR 4.8, CI 95% 2.3–10.2, P<0.001), clinical signs of consolidation (OR 2.0, CI 95% 1.2–3.2, P<0.01) and the Sepsis-Related Organ Failure Assessment (SOFA) Score (OR 1.1, CI 95% 1.1–1.2, P<0.001). Diagnostic confidence increased with CDIS (OR 16.3, CI 95% 8.4–31.4, P<0.001), definite pathogen isolation (OR 3.3, CI 95% 2.0–5.6) and clinical signs of consolidation (OR 2.1, CI 95% 1.3–3.3, P=0.001). Although the CDIS, SOFA Score and the Simplified Acute Physiologic Score (SAPS II) were all associated with mortality, the SAPS II Score was the best predictor of mortality (P=0.02).

Diagnostic confidence for pneumonia is moderate but increases with more classical presentations. A small set of clinical parameters influence subjective assessment. Objective assessment using SAPS II Scoring is a better predictor of mortality.
The Pregnant Trauma Patient
Authors: Weinberg L. , Steele R. G. , Pugh R. , Higgins S. , Herbert M. , Story D.
Published: January 2019

Trauma is the leading non-obstetric cause of maternal death. Optimal management of the pregnant trauma patient requires a multidisciplinary approach. The anaesthetist and critical care physician play a pivotal role in the entire continuum of fetomaternal care, from initial assessment, resuscitation and intraoperative management, to postoperative care that often involves critical care support and patient transfer. Primary goals are aggressive resuscitation of the mother and maintenance of uteroplacental perfusion and fetal oxygenation by the avoidance of hypoxia, hypotension, hypocapnia, acidosis and hypothermia. Recognizing and understanding the mechanisms of injury, the factors that may predict fetal outcome, and the pathophysiological changes that can result from trauma, will allow early identification and treatment of fetomaternal injury. This in turn should improve morbidity and mortality. A framework for the acute care of the pregnant trauma patient is presented.
Comparative Study between Propofol in a Long-chain Triglyceride and Propofol in a Medium/Long-chain Triglyceride during Sedation with Target-controlled Infusion
Authors: Yamakage M. , Iwasaki S. , Jeong S-W. , Ishiyama S-I. , Namiki A.
Published: January 2019

This study was performed to compare the pharmacological characteristics of propofol in an emulsion of both medium- and long-chain triglycerides (MCT/LCT) with those of propofol in an LCT emulsion, by measuring the sedative level and the plasma concentration of propofol during sedation using a target-controlled infusion (TCI) technique. Forty ASA 1 or 2 adult patients who required spinal anaesthesia for surgery were enrolled in this study. The patients were divided into two groups: a propofol LCT group (n=20) and a propofol MCT/LCT group (n=20). Propofol was injected intravenously at target blood concentrations of 2.0, 3.0 and 4.0 μg.ml–1. The bispectral (BIS®) index was recorded, and arterial blood was drawn to measure the actual plasma concentrations of propofol at each predicted concentration. Propofol was assayed by high-performance liquid chromatography. Propofol MCT/LCT was associated with significantly less pain than propofol LCT (P<0.05). There were no significant differences between the two groups in BIS® index or in plasma concentration of propofol at each predicted concentration. Computer-generated TCI of propofol MCT/LCT during sedation is comparable with that of propofol LCT with respect to pharmacokinetics and pharmacodynamics. The formulation of MCT/LCT has a beneficial effect with respect to less pain on injection.
Differential Anaesthetic Effects following Microinjection of Thiopentone and Propofol into the Pons of Adult Rats: A Pilot Study
Authors: Voss L. J. , Young B. J. , Barnard J. P. , Sleigh J.
Published: January 2019

Identifying the central nervous system sites of action of anaesthetics is important for understanding the link between their molecular actions and clinical effects. The aim of the present pilot study was to compare the anaesthetic effect of bilateral microinjections of propofol and thiopentone (both 200 μg/μl, in Intralipid and 0.9% saline respectively) into a recently discovered anaesthetic-sensitive region in the rat brainstem, the “mesopontine tegmental anaesthetic area” (MPTA). Microinjections (1 μl per side) were made into the MPTA of fifteen male Sprague-Dawley rats. The effect of each agent on spontaneous behaviour, postural control and nociceptive responsiveness was subjectively assessed according to established criteria. The main finding was that thiopentone induced an “anaesthesia-like” state, including complete atonia and loss of righting ability, in 20% of the subjects. Overall, thiopentone significantly reduced postural control and had a moderate antinociceptive effect compared to saline microinjections (P<0.01 and 0.05, respectively, Wilcoxon test). In contrast, propofol did not induce “anaesthesia” in any animal tested, although a similar antinociceptive effect to that of thiopentone was observed (P<0.05, Wilcoxon test). In summary, propofol and thiopentone have different effects when microinjected into the MPTA. While both agents reduced reflex withdrawal to a nociceptive stimulus, only thiopentone induced an “anaesthesia-like” state.
Severe Transfusion-related Acute Lung Injury in the Intensive Care Unit Secondary to Transfusion of Fresh Frozen Plasma
Authors: Rajan G. R.
Published: January 2019

Transfusion-related acute lung injury (TRALI) is a life-threatening complication of transfusion of blood products. A case of severe TRALI secondary to infusion of fresh frozen plasma in the intensive care unit is discussed. Additionally, the aetiology and pathogenesis of this relatively under-diagnosed and under-reported clinical entity is reviewed. It is our conclusion that proper diagnosis and reporting is necessary for prompt and appropriate treatment of the patient and to prevent additional reactions in other patients.
Anaesthesia for Major Orthopaedic Surgery in a Child with an Acute Tracheobronchial Injury
Authors: Graham J. , Davidson A. J.
Published: January 2019

A 12-year-old boy presented after a motorbike accident with mediastinal and cervical emphysema but no pneumothorax, minor head injury and several fractures including a comminuted open leg fracture. The child had no signs of respiratory compromise and was stable. The presumed tracheobronchial injury was managed conservatively. To avoid general anaesthesia and the risks associated with intubation and ventilation, urgent surgery for correction of his orthopaedic injuries was successfully conducted under spinal, epidural and intravenous regional anaesthesia. The surgical and anaesthetic management of tracheobronchial injury is complex and controversial.
Postoperative Changes in Prothrombin Time following Hepatic Resection: Implications for Perioperative Analgesia
Authors: Weinberg L. , Scurrah N. , Gunning K. , Mcnicol L.
Published: January 2019

Disorders of coagulation may occur after uncomplicated hepatic resection in patients who have normal preoperative coagulation profiles and liver function tests. We present a retrospective study performed in a tertiary care university teaching hospital examining changes in liver function tests and coagulation profiles in patients undergoing hepatic resection. Data were obtained for 124 patients. When compared to the preoperative values, prothrombin times were significantly increased throughout the postoperative period. Prolongation of the prothrombin time was related to both duration of surgery and hepatic resection weight. There was no relationship between prothrombin time and patient age. Disorders of coagulation occur after hepatic resection even in patients who have normal preoperative coagulation and liver function tests. This has implications for anaesthetic practice, particularly when considering the use of an indwelling epidural catheter in patients undergoing hepatic resection.
Sub-Tenon Block: A Learning Curve of 100 Cases
Authors: Clarke J. P. , Roberton G. , Plummer J.
Published: January 2019

This study measures the learning curve for accomplishing sub-Tenon blocks for ophthalmic surgery applicable to anaesthetists skilled in peribulbar techniques. We defined criteria for a good block in terms of Chemosis, subconjunctival haemorrhage, globe movement and the need for additional peribulbar block. The overall success rate, by our definitions, was 72% and 56% for the two operators. The overall requirement for an additional peribulbar block was 10%). The rate of additional blocks and reduction in globe movement reached a plateau after about 60 procedures for both operators. The rates of Chemosis (6% and 12% overall) and subconjunctival haemorrhage (6% and 12% overall) did not trend with increased experience. The results applied to both a cataract and a vitreo-retinal surgery casemix.
Diagnostic Dilemmas and Management of Fulminant Myocarditis
Authors: Ahmar W. , Leet A. , Morton J.
Published: January 2019

Myocarditis is commonly a diagnosis of exclusion. We report a case of fulminant myocarditis in a patient with cardiogenic shock in whom the initial diagnosis was unclear. Early supportive care including extracorporeal membrane oxygenation and intraaortic balloon pump were instituted. Complete recovery of cardiac function was achieved. This case highlights the difficulty in diagnosing myocarditis and the benefits of early intensive support.
Use of Intrathecal Midazolam to Improve Perioperative Analgesia: A Meta-Analysis
Authors: Ho K. M. , Ismail H.
Published: January 2019

Intrathecal midazolam binds with gamma aminobutyric acid-A receptors in the spinal cord leading to an analgesic effect. Clinical studies suggested that intrathecal midazolam may also reduce nausea and vomiting when used as an adjunct to other spinal medications. However, the potential neurotoxic effect of intrathecal midazolam remains a concern. This meta-analysis aims to evaluate the effectiveness and side-effects of intrathecal midazolam in the perioperative and peripartum settings. Thirteen randomised controlled studies from MEDLINE (from 1966 to July 1 2007), EMBASE and Cochrane Controlled Trials Register databases, involving a total of 672 patients, were considered. Volunteer, animal and chronic pain studies were excluded. Adding intrathecal midazolam to other spinal medications reduced the incidence of nausea and vomiting (odds ratio 0.50, 95% confidence interval [CI] 0.27 to 0.90, P=0.02; I 2 =4%) and delayed the time to request for rescue analgesia (weighted-mean-difference=98.7 min, 95% CI: 76.1 to 121.4, P <0.00001; I=98.5%). Intrathecal midazolam did not affect the duration of motor blockade (weighted-mean-difference =25.1 min, 95% CI -7.6 to 57.8, P=0.13, I 2 =94.8%). The incidence of neurological symptoms after intrathecal midazolam was uncommon (1.8%) and did not differ from placebo (odds ratio 1.20, 95% CI 0.22 to 6.68, P=0.84). Based on the limited data available, intrathecal midazolam appears to improve perioperative analgesia and reduce nausea and vomiting during caesarean delivery. A multicentre registry or large randomised controlled study with a prolonged follow-up period would be useful to confirm the clinical safety of intrathecal midazolam.
Randomised Comparison of the Classic Laryngeal Mask Airway™ with the Cobra Perilaryngeal Airway™ during Anaesthesia in Spontaneously Breathing Adult Patients
Authors: Andrews D. T. , Williams D. L. , Alexander K. D. , Lie Y.
Published: January 2019

We tested the hypothesis that the Cobra Perilaryngeal Airway (PLA) with its high volume low-pressure cuff would provide superior airway leakage pressure compared with the Classic Laryngeal Mask Airway (LMA) in spontaneously breathing adult patients. Ninety consecutive adult patients were randomly allocated to receive one of these two supralaryngeal devices. The airway leakage pressure was higher for the PLA compared with the LMA (22±9 cmH2O vs. 18±6 cmH2O; P <0.05). The mean airway device intracuff pressure was lower for the PLA compared to the LMA (36.1±15.2 mmHg vs. 86.3±25.3 mmHg P <0.0001). The time required to achieve successful insertion was greater for the PLA compared with the LMA (39±21 seconds vs. 27±10 seconds; P <0.005). The number of attempts required to achieve successful insertion and the incidence of postoperative complications were similar in both groups. The findings suggest that the PLA provides a superior airway seal at a lower intracuff pressure compared to the LMA. However, the time for successful insertion may be increased.
Effect of Remifentanil on Tracheal Intubation Conditions and Haemodynamics in Children Anaesthetised with Sevoflurane and Nitrous Oxide
Authors: Park K. S. , Park S. Y. , Kim J. Y. , Kim J. S. , Chae Y. J.
Published: January 2019

This study examined the effect of remifentanil added to inhalation agents on intubating conditions in children (aged one to seven years). As is our routine, all patients were premedicated with 0.004 mg/kg glycopyrrolate intramuscularly 30 minutes before anaesthesia to prevent bradycardia and salivary secretion, and received intravenous 1 mg/kg ketamine prior to transfer into the operating room to facilitate separation of the child from the parents. Laryngoscopy was attempted after ventilation with 8% sevoflurane in 50% nitrous oxide and 50% oxygen for two minutes, and intravenous administration of either a placebo bolus of saline (Group S) or one of two doses of remifentanil, 1 μg/kg (Group R1) or 2 μg/kg (Group R2) given over 30 seconds, commenced at the beginning of the sevoflurane administration. Only 18 of 32 patients (56.3%) in Group S had acceptable intubating conditions compared with 31 of 32 patients (96.9%) in Group R1 and 32 of 32 patients (100%) in Group R2 (P <0.001). Mean blood pressure was lower in Group R1 and R2 compared with Group S (P <0.005). Our routine use of ketamine and glycopyrrolate may have influenced the relative lack of significant hypotension and bradycardia. Sevoflurane, nitrous oxide and remifentanil provided acceptable conditions for tracheal intubation in children and could be an acceptable alternative to intravenous induction and neuromuscular blocking agents.
Loss of Resistance to Saline Reduces Responses Accompanying Spinal Needle Insertion during Institution of ‘Needle-Through-Needle’ Combined Spinal-Epidural Analgesia
Authors: van den Berg A. A. , Ghatge S. , Wang S.
Published: January 2019

Normal saline or air is used to identify loss of resistance during identification of the epidural space for combined spinal-epidural analgesia. Following epidural needle placement using air for loss of resistance, up to 80% of parturients move, grimace, vocalise or experience paraesthesia or dysaesthesia during subsequent dural puncture by a spinal needle. We compared the effects of saline versus air for loss of resistance on the occurrence of these subjective and objective responses during thecal penetration. With institutional approval, 55 parturients presenting for labour analgesia were studied. After infiltration of lignocaine at an L2-L5 vertebral interspace, a 17 gauge Tuohy epidural needle attached to a 5 ml loss of resistance syringe containing either saline or air was inserted and advanced until loss of resistance was identified by injection of 3 to 5 ml of content. During subsequent ‘needle-through-needle’ insertion of a 27 gauge pencil-point spinal needle through the meninges, all subjective and objective patient responses were recorded, as well as each patient's reply to the question “Did you feel that?”. The two groups (n=28, n=27) were comparable. In those given saline and air respectively, 5 (18%) and 12 (44%) parturients responded to and/or acknowledged having perceived dural puncture (P <0.005). Overall, 7 and 31 (P <0.0005) subjective and objective responses occurred during dural puncture in those given saline and air, respectively. The study found that use of saline to determine loss of resistance is associated with fewer patient responses at the moment of thecal penetration during ‘needle-through-needle’ placement of the spinal needle at combined spinal-epidural analgesia.
Comparison between Conventional and Protective One-Lung Ventilation for Ventilator-Assisted Thoracic Surgery
Authors: Ahn H. J. , Kim J. A. , Yang M. , Shim W. S. , Park K. J. , Lee J. J.
Published: January 2019

Recent papers suggest protective ventilation (PV) as a primary ventilation strategy during one-lung ventilation (OLV) to reduce postoperative pulmonary morbidity. However, data regarding the advantage of the PV strategy in patients with normal preoperative pulmonary function are inconsistent, especially in the case of minimally invasive thoracic surgery. Therefore we compared conventional OLV (VT 10 ml/kg, FiO2 1.0, zero PEEP) to protective OLV (VT 6 ml/kg, FiO2 0.5, PEEP 5 cmH2O) in patients with normal preoperative pulmonary function tests undergoing video-assisted thoracic surgery. Oxygenation, respiratory mechanics, plasma interleukin-6 and malondialdehyde levels were measured at baseline, 15 and 60 minutes after OLV and 15 minutes after restoration of two-lung ventilation. PaO2 and PaO2/FiO2 were higher in conventional OLV than in protective OLV (P P <0.05); however, the magnitudes of increase were not different between the groups. Postoperatively there were no differences in the number of patients with PaO2/FiO2 <300 mmHg or abnormalities on chest radiography. Protective ventilation did not provide advantages over conventional ventilation for video-assisted thoracic surgery in this group of patients with normal lung function.
Effectiveness of a Patient Blood Management Data System in Monitoring Blood use in Western Australia
Authors: Mukhtar S. A. , Leahy M. F. , Trentino K. , Koay A. , Semmens J. B. , Tovey J. , Jewlachow V. , Farmer S. L. , Hofmann A. , Roberts H. A. , Towler S. C.
Published: January 2019

The aim of this paper is to describe a linked patient blood management (PBM) data system and to demonstrate its usefulness by presenting the blood usage data obtained.

Our existing datasets already collected much of the required information in relation to PBM. However, these datasets were not linked. A patient identifier was used to link the Patient Administration System with the Laboratory Information System. Data linkage was achieved by linking the Laboratory Information System with the Patient Administration System records where blood transfusion or laboratory result date/time fell between admission and discharge date/time. The two datasets were then consolidated into the PBM data system.

Blood usage data obtained from the system showed that between August 2008 and July 2009 there were 59,627 patient completed separations in the pilot hospital. Of the total transfused units, 62% were red blood cells (RBC), followed by fresh frozen plasma (22%), cryoprecipitate (9%) and platelets (8%). Around 50% of RBC transfusions were administered to patients >70 years of age. General medicine represented 21% of RBC usage, followed by haematology (19%), orthopaedics (17%) and general surgery (16%). Patients with 100 g/1 pre-transfusion haemoglobin received 9% of RBC transfusions and patients with 71–100 g/1 pre-transfusion haemoglobin received 73% of RBC transfusions. The post-transfusion haemoglobin in RBC transfusions exceeded 100 g/1 in 33% of patients.

Databases were successfully linked to produce a powerful tool to monitor blood utilisation and transfusion practices within a pilot PBM program. This will facilitate effective targeting of PBM strategies and ongoing monitoring of their impact.
The Teaching Portfolio as a Professional Development Tool for Anaesthetists
Authors: Sidhu N. S.
Published: January 2019

A teaching portfolio (TP) is a document containing a factual description of a teacher's teaching strengths and accomplishments, allowing clinicians to display them for examination by others. The primary aim of a TP is to improve quality of teaching by providing a structure for self-reflection, which in turn aids professional development in medical education. Contents typically include a personal statement on teaching, an overview of teaching accomplishments and activities, feedback from colleagues and learners, a reflective component and some examples of teaching material. Electronic portfolios are more portable and flexible compared to paper portfolios. Clinicians gain the most benefit from a TP when it is used as a tool for self-reflection of their teaching practice and not merely as a list of activities and achievements. This article explains why and how anaesthetists might use a TP as a tool for professional development in medical education.
The Relationship between Superior Vena Cava Diameter and Collapsibility and Central Venous Pressure
Authors: Cowie B. S. , Kluger R. , Rex S. , Missant C.
Published: January 2019

The aim of this study was to assess the relationship between superior vena cava (SVC) diameter, collapsibility and central venous pressure (CVP) in cardiac surgical patients. SVC maximum and minimum diameters, plus collapsibility with ventilation, were measured with transoesophageal echocardiography in the mid-oesophageal bicaval view with M-mode. Simultaneously, CVP was measured via the right atrial port of a pulmonary artery catheter. Measurements were possible in 91 out of 92 patients. The median CVP was 10 mmHg with a range of 2 to 19 mmHg. There was a weak, but statistically significant, correlation between CVP and SVC collapsibility index (r=-0.21, P=0.049). There was no statistically significant correlation between maximum SVC diameter and CVP. Maximum SVC diameter was statistically significantly correlated with weight (Pearson's r=0.28, P=0.008). There was no statistically significant correlation between CVP and age or body dimensions. Our findings indicate that SVC diameter and collapsibility are easily measured with transoesophageal echocardiography but do not reliably reflect CVP in anaesthetised cardiac surgical patients.
Negative or Positive? The Iron Lung and Poliomyelitis—Zurich, 1951
Authors: Eichel T. , Dreux M. L.
Published: January 2019

During the poliomyelitis epidemics of the last century hospitals were inundated with patients in acute respiratory failure. Between 1946 and 1949, Nandor (Ferdinand) Eichel documented the use of the iron lung in children with acute poliomyelitis at the University Children's Hospital, Zurich. The aim was to assess the effectiveness of the Iron lung and negative pressure respiratory support for this indication and to establish its role in the context of other existing therapies at the time. Eichel produced his review and data as the Inaugural Dissertation towards his medical degree from the the University of Zurich, published in 1951. The dissertation was written in German and first translated into English in 2014. The current paper explores the findings of the dissertation and explains why there has been the transition to techniques of respiratory support today. It includes a biography of Dr F. N. Eichel and an update on the current status of poliomyelitis. The original dissertation was found in the home of Nandor's son and was of great interest to the current authors, Nandor's granddaughter and her colleague.
The Effect of Circulation Time on the Neuromuscular Action of Suxamethonium
Authors: Harrison G. A. , Junius F.
Published: January 2019

In 22 patients about to undergo cardiac surgery, a study was made of the effects of variations in circulation time on the neuromuscular action of suxamethonium. There was a definite relationship between the arm-to-arm circulation time and the time from the injection of suxamethonium to the onset of action, and to the development of 95% depression of the evoked twitch tension in the hypothenar muscles. The circulation time also related to the presence and vigour of fasciculations but not to the duration of action of suxamethonium. The clinical implications are discussed.
Postoperative Analgesia for Haemorrhoid Surgery
Authors: Pybus D. A. , D'Bras B. E. , Goulding G. , Liberman H. , Torda T. A.
Published: January 2019

Seventy patients undergoing haemorrhoidectomy under general anaesthesia were randomly allocated to one of five treatment groups in order to compare the effectiveness of various caudal agents in the control of postoperative pain. Four groups were given a caudal injection of either 2% lignocaine, 0.5% bupivacaine, 2% lignocaine + morphine sulphate 4 mg or normal saline + morphine sulphate 4 mg, while the fifth (control) group did not receive an injection. The number of patients requiring postoperative opiates was significantly higher in the lignocaine group than in the morphine (p <0.05) and morphine-lignocaine (p <0.05) groups. No agent significantly reduced the number requiring opiates. In those who received opiates, the mean analgesic period was 228 minutes in the control group, and was significantly longer following bupivacaine (577 min, p <0.01), morphine-lignocaine (637 min, p <0.05) and morphine (665 min, p <0.01). The mean analgesic period following lignocaine (349 min) was not significantly different from control. The incidence of catheterisation was lowest in those patients who did not receive caudal analgesia.
Clinical Comparison of Atracurium and Alcuronium in Gynaecological Surgery
Authors: Woolner D. F. , Gibbs J. M. , Smeele P. Q.
Published: January 2019

In a double-blind, prospective, randomised trial in 51 female patients, atracurium 0.6mg/kg provided acceptable intubating conditions more rapidly than did alcuronium 0.25mg/kg. Atracurium produced more profound neuromuscular twitch suppression than alcuronium. The effect of atracurium was longer-lasting than that of alcuronium (32 minutes and 22 minutes respectively to achieve 10% recovery) and it took slightly longer to reverse with neostigmine. Seven patients in the atracurium group who underwent short surgical procedures required supplementary neostigmine to achieve adequate reversal. Two cases of sinus bradycardia were noted in the atracurium group, but hypotension was not a clinical problem in any patient. Atracurium appears to be a useful relaxant, but a smaller dose than that used here should be chosen for short procedures.
Physiological Aspects of Intermittent Positive Pressure Ventilation
Authors: Hillman D. R.
Published: January 2019

The mechanical properties of the lungs and chest wall dictate the relationship between tidal volume, flow rate and airway pressure developed during intermittent positive pressure ventilation (IPPV). The increase in intrathoracic pressures associated with IPPV has consequences for the intrapulmonary distribution of ventilation and perfusion (hence gas exchange), cardiac output and regional blood flows. Barotrauma is a potential hazard. IPPV also affects the homeostatic mechanisms that keep the air spaces dry.

Strategies to maximise the benefits and minimise the side effects of IPPV include positive end-expiratory pressure, intermittent mandatory ventilation, differential lung ventilation and high frequency ventilation.

Understanding the physiological effects of IPPV and associated therapies allows a rational approach to the adjustment of ventilation against pulmonary, cardiovascular and systemic responses so as to optimise gas exchange and peripheral oxygen delivery.
The Onset and Duration of Neuromuscular Blockade Using Combinations of Atracurium and Vecuronium
Authors: Gibbs N. M. , Rung G. W. , Braunegg P. W. , Martin D. E.
Published: January 2019

The effect of atracurium-vecuronium combinations on the onset and duration of neuromuscular blockade was investigated in 30 adult patients undergoing general anaesthesia for elective surgery. The patients were randomized to receive either atracurium 0.6 mg.kg−1, vecuronium 0.1 mg.kg−1, or quarter-dose, half-dose, or full-dose combinations of the two drugs. Neuromuscular blockade was assessed by measuring the evoked electromyographic response of the abductor digiti minimi to transcutaneous stimulation of the ulnar nerve. It was found that half-dose combinations of atracurium and vecuronium did not produce a shorter onset time, but did result in a longer duration of neuromuscular blockade than full-doses of either drug alone (P < 0.01). The quarter-dose combinations did not reduce onset time or increase duration. The full-dose combinations produced both a shorter onset time (P < 0.01) and a longer duration (P < 0.001). The results indicate that atracurium-vecuronium combinations are supra-additive in terms of the duration of the neuromuscular blockade produced. However, the inability of atracurium-vecuronium combinations to reduce onset time without increasing duration suggests that there is little advantage in combining the two drugs in clinical practice.
Improving Agreement between Thoracic Bioimpedance and Dye Dilution Cardiac Output Estimation in Children
Authors: O'Connell A. J. , Tibballs J. , Coulthard M.
Published: January 2019

The measurement of thoracic electrical bioimpedance (TEB) offers a continuous, non-invasive method for monitoring cardiac output (CO). For clinical use, agreement with a current standard should be demonstrated. We describe a modification to the manufacturer's suggested data entry into the NCCOM3-R6 TEB monitor (BoMed Medical Manufacturing), which results in improved agreement with indocyanine green dye dilution (DD) CO estimation in paediatric patients. The manufacturer's instructions for the NCCOM3-R6 include an estimation of the volume of electrically participating thoracic tissue (VEPT) based on body weight. We also estimated the VEPT from direct anatomical measurement of thoracic length and circumference. The mean difference between paired DD and TEB CO using the manufacturer's weight-based instructions was 0.69 l/min with 95% confidence limits 2.34 to −0.96 l/min. The mean difference between the two CO techniques using our calculated VEPT was 0.35 l/min with 95% confidence limits 1.50 to −0.80 l/min. The linear regression correlation coefficient between the two techniques was 0.88 using VEPT estimated from the manufacturer's instructions and 0.94 using our calculated VEPT from measurement of thoracic dimensions. The range of DD CO was 0.41 to 8.35 l/min.
The Systolic Blood Pressure Variation as an Indicator of Pulmonary Capillary Wedge Pressure in Ventilated Patients
Authors: Marik P. E.
Published: January 2019

Animal data have suggested that the systolic pressure variation (SPV) noted during positive pressure ventilation may be a sensitive indicator of hypovolaemia. The aim of this study was to correlate the SPV with the pulmonary capillary wedge pressure (PCWP) in a heterogeneous group of ICU patients on volume-cycled ventilation.

Three hundred data sets were collected on 226 patients. The correlation coefficient between the SPV and PCWP for the first half of the data set was - 0.84 (P<0.001). The linear regression formula from this data set was: PCWP = 20- (SPV*0.7). Using this formula the predicted PCWP was then correlated with the measured PCWP using the second half of the data base. The correlation coefficient was 0.87 (P<0.001). The correlation coefficient between the SPV and PCWP for the entire data base (300 observations) was -0.86 (P<0.001).

It is concluded that analysis of the arterial pressure tracing may be useful in estimating the pulmonary capillary wedge pressure in ventilated patients.
Acute Normovolaemic Haemodilution and Idiopathic Scoliosis Surgery: Effects on Homologous Blood Requirements
Authors: Olsfanger D. , Jedeikin R. , Metser U. , Nusbacher J. , Gepstein R.
Published: January 2019

After the introduction of acute normovolaemic haemodilution (NVHD) in our hospital, we prospectively studied 19 patients managed with moderate NVHD (mean haematocrit 0.28, SD 0.02) during idiopathic scoliosis surgery (mean angle 53.2, SD 16.7 degrees) with the Cotrel-Dubousset instrumentation (CDI). Our standard scoliosis anaesthetic technique was used. Intraoperatively, one patient received one unit of homologous blood. Postoperatively, seven patients received ten units of homologous blood. Homologous blood used was reduced by about 83% for this procedure in our institution. In the assessment of fluid and blood requirements we found physical signs reflecting tissue perfusion and oxygen supply more reliable than the estimated blood loss using the suction bottle and swabs. The similar postoperative complications (nine fever, five atelectasis/pneumonia, one urinary infection, one phlebitis), anaesthetic duration (mean 5.21, SD 1.13) hours, hospitalisation (mean 6.67, SD 1.19) days and return to normal activity (mean 8, SD 7.68) weeks indicate that the NVHD patients did just as well as with our previous regimen when only homologous blood was used.
Tracheal Gas Insufflation Reduces Requirements for Mechanical Ventilation in a Rabbit Model of Respiratory Distress Syndrome
Authors: Bernath M.-A. , Henning R.
Published: January 2019

Tracheal gas insufflation is known to lower Paco2 in larger animal models of respiratory distress syndrome, but its ability to reduce the ventilator pressures and tidal volume needed to achieve an acceptable Paco2 has not been examined in small animals using modes of ventilation employed in neonatal intensive care. In this study, the effect of insufflating humidified gas into the lower trachea was examined in a saline lung lavage model of respiratory distress syndrome in rabbits, while the peak airway pressure during conventional pressure-limited ventilation was adjusted to keep the Paco2 approximately constant. Tracheal gas insufflation significantly reduced the peak airway pressure required and reduced the delivered tidal volume but did not affect the AaDO2. The effects were more marked at a ventilator rate of 30 breaths per minute than at 60 bpm and more during continuous insufflation than when gas was insufflated only during expiration. These results suggest that tracheal gas insufflation may reduce the risk of ventilation-induced lung disease in the newborn.
Changes in Respiratory Mechanics during Abdominal Laparoscopic Surgery in Children
Authors: Bergesio R. , Habre W. , Lanteri C. , Sly P.
Published: January 2019

We designed this study in order to measure the changes in respiratory mechanics during laparoscopic surgery in children. Ventilation parameters (Flow (Ví) and Peak Pressure (Pmax)) were measured and total respiratory system mechanics (resistance (Rrs) and compliance(Crs)) were derived using multiple linear regression analysis in 11 children aged 8 months to 11 years.

The Pmax increased by 26.6% and the Rrs increased by 20.2% whilst the Crs decreased by 38.9% after pneumoperitoneum. These findings suggest that clinically important changes in respiratory mechanics occur as a result of the pneumoperitoneum produced during abdominal laparoscopic surgery.
Collective Resources and Violent Crime Reconsidered: New Orleans Before and After Hurricane Katrina
Authors: Weil Frederick D. , Barton Michael , Rackin Heather , Valasik Matthew , Maddox David
Published: January 2019

Social research has long argued that collective resources and major events like disasters have an important impact on violent crime, but it has been difficult to show their effects because data are scarce. We conducted a large survey in New Orleans after Hurricane Katrina that included questions about collective resources. We aggregated our sample to the census tract level and merged it with data on concentrated disadvantage and violent crime. Our analyses show that bridging social networks are associated with lower levels of violent crime, while bonding social networks are associated with higher levels. Social trust is associated with lower levels of violent crime, but civic engagement has no impact. Concentrated disadvantage is associated with higher levels of violent crime. Finally, our results suggest that disaster recovery increased the importance of collective resources but not concentrated disadvantage on violent crime.
Finite element modeling of interaction between non-pneumatic mechanical elastic wheel and soil
Authors: Deng Yao-Ji , Zhao You-Qun , Xu Han , Zhu Ming-Min , Xiao Zhen
Published: January 2019

The tire/soil interaction is an important and complex research topic in vehicle-terrain mechanics, which has a great influence on vehicle mobility and soil compaction. The purpose of this work was to develop a detailed nonlinear finite element model for parametric analysis of the interaction between mechanical elastic wheel and the soil. The three-dimensional finite element model of the mechanical elastic wheel, which considers material nonlinearity, geometric nonlinearity, as well as large contact deformation between the mechanical elastic wheel and soil, was developed based on the physical model. The reliability and accuracy of the finite element model were validated by comparing the predicted wheel static loading characteristics in rigid plane with those of experiments. The finite element model of the soil is modeled as a two-layer system and the Extended Drucker–Prager model was used to describe the nature soil properties. The deformation and stress of the soil and mechanical elastic wheel under the static loading condition were studied in detail. Moreover, the effects of the axial load on mechanical elastic wheel/soil interaction were also analyzed. The research results could offer reference for an optimum structural design of a mechanical elastic wheel and a prediction of soil compaction caused by non-pneumatic tires.
Valuing creativity, feeling overworked and working hours: Male workers and the New Spirit of Capitalism
Authors: Samuel Robin , Kanji Shireen
Published: January 2019

Boltanski and Chiapello argued that creativity is a required attribute of managers emanating from the ideology of the ‘New Spirit of Capitalism’. Ideology provides the justification for work practices and brings material consequences in relation to the experience of time. This article explores both the ideology and the links between the ideological and the experience of time by assessing whether male managers prioritise creativity and whether this is related to their working hours, driving them to work longer hours than other workers and longer hours than they actually want. Men’s dominant position in work organisations puts them at the centre of this exploration. Using multilevel linear and logistic models on 2010 data from the European Social Survey ( N = 7049), we show that male managers prioritise creativity more than other workers do. There are consequences for the experience of time as valuing creativity in combination with being a manager increases working hours above the large and significant effect of being a manager. The feeling of overwork is raised independently for those who value creativity and for those who are managers.