bluuebunny/crossref_metadata_2025 huggingface dataset:
Anaesthetic Management of a Patient with Emery-Dreifuss Muscular Dystrophy
Authors: Shende D. , Agarwal R.
Published: January 2019

Emery-Dreifuss muscular dystrophy is a rare form of muscular dystrophy associated with cardiac implications such as cardiomyopathy and arrhythmias leading to sudden death. We describe the anesthetic management of a patient with Emery-Dreifuss muscular dystrophy who presented for orthopaedic surgery and discuss the disorder and its potential anaesthetic implications.
Pharmacodynamics and Atracurium and Laudanosine Concentrations during a Fixed Continuous Infusion of Atracurium in Mechanically Ventilated Patients with Acute Respiratory Distress Syndrome
Authors: Lefrant J-Y. , Farenc C. , De La Coussaye J-E. , Muller L. , Ripart J. , Cuvillon P. , Saissi G. , Eledjam J-J.
Published: January 2019

The present study was designed to assess the pharmacodynamics and the plasma levels of atracurium and laudanosine found during a 72-hour fixed rate infusion of atracurium in acute respiratory distress syndrome patients without renal or liver failure.

Nine sedated and mechanically ventilated acute respiratory distress syndrome patients without renal or liver failure were paralysed with a bolus of atracurium (1 mg.kg -1 ) followed by a 72-hour continuous infusion (1 mg.kg -1 .h -1 ). The count of train-of-four (TOF) and TOF ratio were monitored by an accelerograph until full neuromuscular recovery (T4/T1 0.7). Atracurium and laudanosine concentrations were measured from the onset to four days after cessation of the infusion. An electroencephalogram was recorded daily.

Analysis showed that TOF count was always 3 until cessation of the infusion. Following cessation, neuromuscular recovery occurred between 31 and 96 minutes (median value=45 min). The highest atracurium and laudanosine concentrations ranged from 3.3 to 5.8 μg.ml –1 and from 3 to 20 μg.ml –1 respectively. In four patients with renal impairment, the highest laudanosine concentration was > 10 μg.ml –1. No seizure was recorded.

A fixed infusion rate of atracurium in acute respiratory distress syndrome patients provided an effective muscle paralysis with a rapid neuromuscular recovery but can lead to accumulation of laudanosine in patients with renal impairment.
Effect of Addition of Clonidine to Local Anaesthetic Mixture for Peribulbar Block
Authors: Bharti N. , Madan R. , Kaul H. L. , Khokhar S. K. , Mishra S.
Published: January 2019

Clonidine added to local anaesthetics prolongs the duration of anaesthesia and analgesia of peripheral, neuraxial and retrobulbar blocks. The present randomized blinded controlled study was conducted to evaluate the effect of the addition of clonidine to local anaesthetic mixture on the quality, onset time, duration of peribulbar block, perioperative analgesia and patients’ comfort.

The study comprised two groups of 12 patients each. Group A (control) patients received 7 ml of a mixture of 2% lignocaine and hyaluronidase with 1 ml normal saline, while group B (clonidine group) patients had clonidine 1 μg/kg added to the above mixture. Onset and duration of lid akinesia, globe anaesthesia and akinesia, time to first analgesic medication and total analgesic requirement were assessed. Patients were monitored for heart rate, blood pressure, sedation and respiratory depression.

Addition of clonidine to local anaesthetic mixture resulted in a significant increase in duration of lid akinesia (85.4±25.6 vs 173.3±35.3 min, P<0.001), globe anaesthesia (63.2±6.9 vs 78.8±17.5 min, P=0.012) and globe akinesia (161.3±24.3 vs 201.2±45.7 min, P=0.016). The onset time and quality of block were similar in both the groups. No significant haemodynamic, respiratory or sedative effects were recorded. The perioperative pain scores and the analgesic requirements were significantly (P<0.01) lower in group B patients. We found that addition of clonidine 1 μg/kg to local anaesthetic mixture significantly increases the duration of anaesthesia and analgesia after peribulbar block.
Neurolytic Celiac Plexus Block for Visceral Abdominal Malignancy: Is Prior Diagnostic Block Warranted?
Authors: Yuen T. S. T. , Ng K. F. J. , Tsui S. L.
Published: January 2019

Neurolytic celiac plexus block is a recognised treatment for visceral abdominal pain due to malignancy. The need for a diagnostic celiac plexus block prior to neurolytic blockade is of questionable value, as it may not predict a positive response and may incorrectly predict a lack of response. Our objective is to evaluate the efficacy of diagnostic celiac plexus block. The records of 59 patients treated with celiac plexus block during 1994–2000 were retrospectively reviewed. Diagnostic block was performed on 32 patients prior to the decision for subsequent neurolytic block (Group 1). Another 27 patients were directly treated with a neurolytic celiac plexus block (Group 2). Response of Group 1 to diagnostic and neurolytic blocks was compared. Data from Group 2 was used to project the response of Group 1 should those patients with negative response to diagnostic block proceeded to neurolytic block. A two-by-two table was then constructed. The diagnostic celiac plexus block predicted a positive response with a sensitivity of 93% and a specificity of 37%. The positive predictive value was 85% and the negative predictive value was 58%. The estimated “number needed to test” before a “true” nonrespondent to lytic block to be detected was 16.7. Therefore, a positive response to diagnostic block correlates positively with neurolytic celiac plexus block for abdominal visceral pain due to malignancy. However, diagnostic block is a poor predictor when the response is negative. Hence, its clinical role is questionable and may not be warranted for patients with terminal malignancy.
Risk Factors for Epistaxis during Nasotracheal Intubation
Authors: Sim W. S. , Chung I. S. , Chin J. U. , Park Y. S. , Cha K. J. , Lee S. C. , Kim Y. C.
Published: January 2019

We performed a study to confirm which risk factors are significantly associated with epistaxis during nasotracheal intubation. One hundred patients who underwent nasotracheal intubation were included. Risk factors for epistaxis were analysed using the multiple logistic regression analysis with stepwise variable selection method. Epistaxis was most likely to occur if transit of the tube through the nasal passage was difficult (P=0.0001, odds ratio 6.25, 95% confidence interval 3.14–14.26). On the other hand, age and gender, obesity, smoking, tube size, repeated attempts of intubation, and intubation performed with the aid of Magill forceps were not significantly related with risk of epistaxis. The presence of nasal anatomical abnormalities also did not correlate significantly with epistaxis. Strategies to ensure smooth transit of the tube through the nasal passageways are essential to reduce the incidence of epistaxis.
Peripartum Management of a Patient with Dopamine Beta-hydroxylase Deficiency, a Rare Congenital Cause of Dysautonomia
Authors: Scurrah N. J. , Ross A. W. , Solly M.
Published: January 2019

We present the first reported case involving the peripartum anaesthetic management of dopamine beta-hydroxylase deficiency in a 22-year-old primigravida with high-grade placenta praevia. Elective caesarean section was performed at 36 weeks gestation with a combined spinal-epidural regional anaesthetic technique. Extensive preparation was undertaken to manage the consequences of obstetric haemorrhage and consideration given to potential pharmacological sensitivities suspected to exist in patients with this rare disorder affecting sympathetic nervous system function. An uncomplicated caesarean section was performed from which the patient recovered well to be discharged home with a healthy baby.
Interscalene Brachial Plexus Block for Shoulder Surgery in a Patient with Arthrogryposis Multiplex Congenita
Authors: Sreevastava D. , Trikha A. , Sehgal L. , Arora M. K.
Published: January 2019

A five-year-old child with severe arthrogryposis multiplex congenita and malnutrition underwent surgery for chronic osteomyelitis of the head of the left humerus. The child had typical features of arthrogryposis multiplex congenita, including a difficult airway. Propofol was used for induction and maintenance. Spontaneous respiration was maintained with a nasal airway. Analgesia was provided with an interscalene brachial plexus block placed using a nerve stimulator. No opioid was given. The child had an uneventful recovery with good postoperative analgesia. The anaesthetic implications of arthrogryposis multiplex congenita are discussed.
Bronchial Diameters in Children—Use of the Fogarty Catheter for Lung Isolation in Children
Authors: Tan G. M. , Tan-Kendrick A. P. A.
Published: January 2019

The right and left main bronchial diameters of 250 children were measured using computed tomography of the thorax. In 75% of the cases, the right main bronchial diameter was significantly larger than the left (95% CI 0.7-0.9, P<0.01). Age but not weight of a child is a good predictor of the bronchial diameter (Beta value is 2.81x10 -2 and 2.58 x10 -2 for right and left main bronchial diameter respectively). A size 3 Fogarty catheter will provide effective bronchial blocking for children up to 4 years old. A size 5 Fogarty catheter can be used for most children from 5 to 12 years old. Larger Fogarty catheters or double-lumen tubes can be used in older children. Overinflation of the cuff should be avoided by fibreoptic bronchoscopy of the balloon. Our clinical application of the technique is discussed.
The ASA Physical Status Classification: Inter-observer Consistency
Authors: Mak P. H. K. , Campbell R. C. H. , Irwin M. G.
Published: January 2019

The American Society of Anesthesiologists (ASA) physical status classification system has previously been shown to be inconsistently applied by anaesthetists. One hundred and sixty questionnaires were sent out to all specialist anaesthetists in Hong Kong. Ten hypothetical patients, identical to those of a similar study undertaken 20 years ago, each with different types and degrees of physical disability were described. Respondents were asked about their country of training and type of anaesthetic practice and to assign an ASA classification status for each patient.

Ninety-seven questionnaires were returned (61%) after two mailings. Agreement for each patient within groups, between groups and overall comparisons were made. Percentage of agreement was between 31 to 85%. Overall correlation was only fair in all groups (Kappa indices: 0.21–0.4). We found that the current pattern of inter-observer inconsistency of classification was similar to that 20 years ago and exaggerated between locally and overseas trained specialists (P<0.05). The validity of the ASA system, its usefulness and the need for a new, more precise scoring system is discussed.
An Autologous Blood Donation Program for Paediatric Scoliosis Patients in Hong Kong
Authors: Lo K. S. , Chow B. F. M. , Chan H. T. , Gunawardene S. , Luk K. D. K.
Published: January 2019

A retrospective audit was conducted to determine the safety, efficacy and patient satisfaction related to a preoperative autologous blood donation program for children and teenagers undergoing corrective surgery for scoliosis. Forty-five of the 77 patients donated the requested amount of blood. These 45 compliant patients had been requested to donate fewer units of blood than noncompliant patients (mean 4.0 vs 4.6 respectively, P=0.02). Twelve patients required allogeneic blood transfusion. Two patients had surgery delayed making the collected autologous blood unavailable. The extent of the operation was associated with the need for allogeneic blood transfusion. Six and a half percent of all donated units of blood were discarded. No major complications were reported. Overall, 93% of patients were satisfied with the program. With careful patient selection, good inter-departmental coordination and teamwork, preoperative autologous blood donation in paediatric patients undergoing extensive corrective surgery for scoliosis is safe and effective.
Life–threatening Pulmonary Oedema Secondary to Tracheal Compression
Authors: Butterell H. , Riley R. H.
Published: January 2019

We present a case of negative pressure pulmonary oedema due to an overlooked cause. A 45-year-old female patient presented to the emergency department unconscious with severe pulmonary oedema. Subsequent investigations revealed a thyroid goitre causing significant tracheal compression. This case report highlights an extremely rare but potentially dangerous sequela of upper airway obstruction.
Induction of Anaesthesia in the Home
Authors: Chan W. P. , Chilvers C. R.
Published: January 2019

An intellectually impaired adult with a history of escalating violence towards hospital personnel was given an anaesthetic in his home prior to transfer to hospital for surgery. We review the implications and problems encountered, and suggest means by which such a retrieval can occur smoothly.
High-density EEG Mapping during General Anaesthesia with Xenon and Propofol: A Pilot Study
Authors: Johnson B. W. , Sleigh J. W. , Kirk I. J. , Williams M. L.
Published: January 2019

Anaesthetic-induced spatial inhomogeneities of the electrencephalogram(EEG) using “high density” electrode mapping have not previously been reported. We measured the scalp EEG with a dense electrode (128-channel) montage during the course of light general anaesthesia with xenon and then propofol in normal human subjects. EEG was measured during induction and recovery of general anaesthesia in five normal subjects, and we obtained analysable data from three of these subjects. EEG topographies were plotted on a realistic head surface. Scalp fields were spatially de-blurred using a realistic head model and projected onto an averaged cortical surface Both xenon and propofol elicited large increases in midline frontal theta-band EEG power. Propofol reliably elicited orbitofrontal delta activity. Xenon, but not propofol, caused large increases in delta over the posterior cortex. Increased gamma power was observed for both anaesthetic agents at midline electrodes over the posterior cortex, but not anteriorly. Anaesthesia-induced delta and theta waves were differentially distributed along the anterior-posterior axis of the brain in a manner that corresponds well to the anatomy of putative neuronal generators. The distribution of anaesthetic-induced changes in fast gamma-band power seems to reflect functional differences between the posterior and anterior aspects of the cerebral cortex. These preliminary observations were consistent within our small sample, indicating that larger studies of anaesthetic effects using high-density recordings are warranted.
A Comparison of Four Intravenous Sedation Techniques and Bispectral Index Monitoring in Sinonasal Surgery
Authors: Buyukkocak U. , Ozcan S. , Daphan C. , Apan A. , Koc C.
Published: January 2019

This study was performed to investigate the quality of different intravenous sedation techniques, and the correlation between the Bispectral Index (BIS) values and the Observer's Assessment of Alertness/Sedation (OAA/S) scores.

Eighty patients undergoing sinonasal surgery were randomly assigned to one of four groups. Group MF received midazolam and fentanyl, group PF received propofol and fentanyl, group MR received midazolam and remifentanil, and group PR received propofol and remifentanil.

Heart rate and mean arterial pressuure values were not different among the groups. SpO 2 decreased only after intravenous medication in groups MF and MR (P<0.017). Emesis was less common with propofol. A positive relationship existed between the BIS values and OAA/S scores during the operation in all groups and the strongest correlation was observed in group PR (r=0.565 and P<0.001).

In conclusion, these four intravenous sedation techniques did not change mean arterial pressure, heart rate or SpO 2 clinically and produced a similar level of light sedation. The BIS was useful for monitoring of sedation during sinonasal surgery under local anaesthesia with intravenous sedation.
The Comparative Effects of Propofol versus Thiopentone on Left Ventricular Function during Electroconvulsive Therapy
Authors: Kadoi Y. , Saito S. , Ide M. , Toda H. , Sekimoto K. , Seki S. , Takahashi K. , Goto F.
Published: January 2019

The purpose of this study was to compare the effect of propofol versus thiopentone on haemodynamics during electroconvulsive therapy (ECT), as estimated by echocardiography.

Twenty-eight ASA 1 or 2 patients scheduled for ECT were randomly divided into two groups, to receive propofol 1 mg/kg (propofol group, n=14) or thiopentone 2 mg/kg (thiopentone group, n=14). Bilateral ECT was performed after the administration of propofol or thiopentone, succinylcholine and following assisted mask ventilation with 100% oxygen. Cardiac function was examined by transthoracic echocardiography, prior to induction of anaesthesia and throughout ECT until ten minutes after the seizure.

In the propofol group, increased end-systolic area (ESA) and decreased fractional area change (FAC) were observed at one minute after the electrical shock compared with the awake condition. In the thiopentone group, increased ESA and decreased FAC were observed from one to three minutes after the electrical shock compared with the awake condition. There was no statistically significant change in after load in the propofol group during the study. In contrast, increased after load was observed from one to three minutes after the electrical shock in the thiopentone group (awake condition, 26±7 mmHg/cm 2 [mean±SD]; one minute after ECT, 42±7*; two minutes after ECT, 44±6*; three minutes after ECT; 40±5*, respectively)(*P<0.05).

We concluded that a lesser haemodynamic change occurs after propofol anaesthesia (1 mg/kg) compared with thiopentone anaesthesia (2 mg/kg) during ECT.
Alfentanil Infusion as a Component of Intravenous Anaesthesia for Coronary Artery Bypass Surgery with “Fast-track” Recovery
Authors: Blake D. W. , Royse C. F. , Royse A. G. , Bjorksten A. R. , Soeding P. F. , Pang J.
Published: January 2019

Alfentanil and propofol total intravenous anaesthesia was assessed in 25 patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass (CPB). A manually controlled alfentanil infusion, calculated from estimated lean body mass and published pharmacokinetic data, was effective in achieving target plasma concentrations, while the “Diprifusor” system was used to vary propofol target concentrations according to changes in haemodynamics and anaesthetic requirement. The effects of CPB on alfentanil plasma concentrations were offset by changes in protein binding and free-fraction of the drug. With the use of only two target plasma concentrations for alfentanil (changed after CPB), a pre-determined infusion profile ensured effective plasma concentrations during surgery and concentrations unlikely to inhibit extubation within six hours of sternal closure.
Operation Bali Assist—The Royal Darwin Hospital Intensive Care Unit
Authors: Stephens D.P. , De Keulenaer B. L. , Collins S. , Harbison P. W. , Weidmann G. , Potter A. W.
Published: January 2019

On October 12, 2002 the Bali bombing resulted in 62 severely injured patients being evacuated to Royal Darwin Hospital. This paper describes the planning and execution of the Intensive Care Unit disaster plan in the wake of the Bali bombing. There were a total of 20 patients from the Bali blast admitted to the Intensive Care Unit. The disaster operation was successful with all patients admitted, resuscitated, emergency treatment performed and then evacuated to interstate burns units in a timely and efficient manner.
Immunoglobulin Therapy in Non-menstrual Streptococcal Toxic Shock Syndrome
Authors: Murthy B. V. S. , Nelson R. A. , Mannion P. T.
Published: January 2019

We describe a case of non-menstrual streptococcal toxic shock syndrome requiring high doses of noradrenaline. The intravenous administration of pooled immunoglobulin was associated with improved haemodynamics and weaning of vasoconstrictors.
Levobupivacaine versus Racemic Bupivacaine in Spinal Anaesthesia for Urological Surgery
Authors: Lee Y. Y. , Muchhal K. , Chan C. K.
Published: January 2019

Racemic bupivacaine is the most common local anaesthetic used intrathecally. This prospective, randomized, double-blind study compared the clinical efficacy and motor block of 0.5% levobupivacaine with 0.5% racemic bupivacaine in spinal anaesthesia for urological surgery. The surgery required an upper level of sensory block of at least the tenth thoracic dermatome. Fifty patients were recruited (levobupivacaine group n=24; bupivacaine group n=26). Spinal anaesthesia was achieved with 2.6 ml of study solution injected in the subarachnoid space at the lumbar 3/4 interspace. One patient from the levobupivacaine group was excluded due to technical failure. There were no significant differences between the two groups in the quality of sensory and motor block or in haemodynamic change. Anaesthesia was adequate and patient satisfaction good in all cases.

We conclude that 0.5% levobupivacaine can be used as an alternative to 0.5% racemic bupivacaine in spinal anaesthesia for surgery when a sensory block to at least T10 is required.
Post Anaesthesia Care Unit Discharge: A Clinical Scoring System versus Traditional Time-based Criteria
Authors: Truong L. , Moran J. L. , Blum P.
Published: January 2019

This prospective cohort analysis compared the efficiency of time-based discharge criteria (Group 1) to a modified clinical scoring system (Group 2), incorporating the assessment of pain and temperature, in the post anaesthesia care unit (PACU). Two consecutive series of patients (n=292) were assessed following general anaesthesia for various surgical procedures. The time taken for patients to satisfy their respective discharge criteria was recorded as PACU length of stay (LOS). Patient group and other factors that may have influenced PACU-LOS were examined using time-to-event analysis. The raw PACU-LOS was not shown to be different between the two groups (log rank test, P=0.12). Covariate adjusted estimates were used to compare the two discharge criteria and also to identify other factors influencing PACU-LOS. The Cox regression model was poorly specified and a log-logistic accelerated failure time model was found to be the most parsimonious predictive model.

Predictors of decreased PACU-LOS were the treatment group (Group 2 versus Group 1) and the covariate recording anaesthetic airway choice (no endotracheal tube (ETT) versus ETT). Surgical time, as a linear function, intra- and postoperative opioid administration, as well as postoperative antiemetic use were predictors of increased PACU-LOS. Patient age, gender, urgency of surgery, and ASA classification were not predictive of PACU-LOS. Using covariate adjusted estimates, the new PACU discharge criteria, based on the Aldrete's scoring system, was associated with a significantly reduced PACU-LOS in comparison with time-based criteria.
Criteria for Elective Admission to the Paediatric Intensive Care Unit following Adenotonsillectomy for Severe Obstructive Sleep Apnoea
Authors: Walker P. , Whitehead B. , Rowley M.
Published: January 2019

During the period 1997 to 2002, 42 children were electively admitted to the Paediatric Intensive Care Unit at the John Hunter Children's Hospital following adenotonsillectomy for severe obstructive sleep apnoea. Forty children had a preoperative sleep study, of which 33 were complete polysomnograms. Of the 42 children admitted, 35 required no intervention while seven (17%) required an additional intervention beyond supplemental oxygen. Our criteria for elective admission to Paediatric Intensive Care following adenotonsillectomy for severe obstructive sleep apnoea are presented.
An Evaluation of the Modified Airway Management Device
Authors: Chiu C. L. , Wang C. Y.
Published: January 2019

This is a preliminary report on the use of the modified Airway Management Device in 50 spontaneously breathing patients undergoing elective day care surgery.

We were successful in establishing a clear airway in all 50 patients, 46 of these patients had a patent airway on the first attempt. All patients were successfully managed with the Airway Management Device throughout the surgery.

Partial airway obstruction during maintenance of anaesthesia occurred in three cases requiring only minor manipulations. Our result showed that the Airway Management Device may be used as an alternative airway management in anaesthesia.
Myelopathy with Syringomyelia following Thoracic Epidural Anaesthesia
Authors: Aldrete J. A. , Ferrari H.
Published: January 2019

Under general anaesthesia and muscle relaxation, a thoracic epidural catheter was inserted at the T8-T9 level in a 7-year-old boy scheduled to have a Nissen fundoplication to provide postoperative analgesia. After 4 ml of lignocaine 1.5% was injected through the catheter, hypotension resulted. Fifty-five minutes later 5 ml of bupivacaine 0.25% produced the same effect. In the recovery room a similar injection resulted in lower blood pressure and temporary apnoea. Sensory and motor deficits were noted the next day and four days later magnetic resonance imaging demonstrated spinal cord syringomyelia extending from T5 to T10. Four years later, dysaesthesia from T6 to T10 weakness of the left lower extremity and bladder and bowel dysfunction persist. The risks of inserting thoracic epidural catheters in patients under general anaesthesia and muscle relaxation are discussed, emphasising the possibility of spinal cord injury with disastrous consequences.
Patient-controlled Epidural Analgesia following Combined Spinal-epidural Analgesia in Labour: The Effects of Adding a Continuous Epidural Infusion
Authors: Missant C. , Teunkens A. , Vandermeersch E. , Van De Velde M.
Published: January 2019

Patient-controlled epidural analgesia (PCEA) is used to maintain epidural analgesia following initial intrathecal analgesia. This trial investigated whether a continuous background infusion with PCEA provides superior analgesia to PCEA alone among patients who received combined spinal-epidural (CSE) analgesia during labour.

Eighty parturients were randomized to either PCEA alone (PCEA) or PCEA with a background infusion of ropivacaine 0.15% with sufentanil 0.75 μg/ml at 2 ml/h (PCEA+CEI). PCEA settings were a bolus of 4 ml of the same analgesic solution with a lockout interval of 15 minutes.

Significantly more patients in the PCEA group required at least one anaesthetist intervention for breakthrough pain (27 [71%] vs 10 [25%] in the PCEA+CEI group, P<0.05). Consumption of local anaesthetic (excluding manually administered boluses) was similar between the groups. If anaesthetist-administered boluses were included, more local anaesthetic was consumed by the PCEA group (47.1±19.4 mg vs 35.6±12.0 mg in the PCEA+CEI group, P<0.05).

We conclude that PCEA with a background infusion provides effective analgesia with less anaesthetist workload and reduced local anaesthetic consumption as compared with PCEA without a background infusion.
The Relationship between Oxygenator Exhaust Pco2 and Arterial Pco2 During Hypothermic Cardiopulmonary Bypass
Authors: Graham J. M. , Gibbs N. M. , Weightman W. M. , Sheminant M. R.
Published: January 2019

During cardiopulmonary bypass the partial pressure of carbon dioxide in oxygenator arterial blood (Paco2) can be estimated from the partial pressure of gas exhausting from the oxygenator (PEco2). Our hypothesis is that PEco2 may be used to estimate Paco2 with limits of agreement within 7 mmHg above and below the bias. (This is the reported relationship between arterial and end-tidal carbon dioxide during positive pressure ventilation in supine patients.)

During hypothermic (28-32°C) cardiopulmonary bypass using a Terumo Capiox SX membrane oxygenator, 80 oxygenator arterial blood samples were collected from 32 patients during cooling, stable hypothermia, and rewarming as per our usual clinical care. The Paco2 of oxygenator arterial blood at actual patient blood temperature was estimated by temperature correction of the oxygenator arterial blood sample measured in the laboratory at 37°C. PEco2 was measured by connecting a capnograph end-to-side to the oxygenator exhaust outlet. We used an alpha-stat approach to cardiopulmonary bypass management.

The mean difference between PEco2 and Paco2 was 0.6 mmHg, with limits of agreement (±2 SD) between -5 to +6 mmHg. PEco2 tended to underestimate Paco2 at low arterial temperatures, and overestimate at high arterial temperatures.

We have demonstrated that PEco2 can be used to estimate Paco2 during hypothermic cardiopulmonary bypass using a Terumo Capiox SX oxygenator with a degree of accuracy similar to that associated with the use of end-tidal carbon dioxide measurement during positive pressure ventilation in anaesthetized, supine patients.
Experiences of Anticholinesterase Pesticide Poisonings in an Australian Tertiary Hospital
Authors: Roberts D. M. , Fraser J. F. , Buckley N. A. , Venkatesh B.
Published: January 2019

There is limited information regarding the management and outcomes of patients presenting with anticholinesterase pesticide poisoning in Australia. Patients presenting to a tertiary referral hospital with anticholinesterase exposures were identified by discharge coding. The medical records of each patient were retrospectively reviewed. Based on clinical outcome, patients were classified as severe or non-severe poisonings. Forty-one presentations were noted between 1990 and 2003. Eight patients (20%) had severe poisoning of which tachycardia, fasciculations with weakness and metabolic acidosis were common manifestations. The diagnosis was delayed in four patients due to the absence of a clear history, which did not influence patient outcomes or put hospital staff at risk of nosocomial poisoning. The median length of hospital stay was prolonged in severe poisonings (20 days) compared to 12 hours in other patients. Two cases of intermediate syndrome were attributed to fenthion and diazinon, and one case of delayed polyneuropathy to trichlorfon. Cholinesterase activities were performed in only 49% of presentations. The overall mortality was 2.4% (1 death) and the mortality in patients with severe poisoning was 12.5%. The incidence of anticholinesterase poisoning in Australia is low. These outcomes were favourable and comparable with other published data. Measures to enhance the knowledge of medical staff supplemented by validated treatment protocols should be developed. For less significant exposures, an emphasis on adequate documentation of cholinergic signs and cholinesterase activities is necessary for rapid triage and may also have potential forensic implications if not performed.
Assessment of Diaphragmatic Function with Cervical Magnetic Stimulation in Critically Ill Patients
Authors: Buscher H. , Valta P. , Boie T. , Hinz J. , Moerer O. , Sydow M. , Mudaliar M. Y. , Burchardi H.
Published: January 2019

The objective of this study was to evaluate a non-volitional measurement to assess diaphragmatic function in intubated and mechanically ventilated patients in a prospective pilot interventional clinical trial. The study was conducted in an 18-bed postoperative intensive care unit based at a university hospital. Patients were prospectively assigned to two groups. Group 1 consisted of eight patients with ventilator weaning failure. Group 2 consisted of eight intubated and ventilated patients who were studied shortly after major surgery and were successfully extubated thereafter. The twitch pressure response after cervical magnetic stimulation of the phrenic nerves was measured at the endotracheal tube at different PEEP levels. In group 2 the twitch transdiaphragmatic pressure, defined as the difference between twitch gastric and twitch oesophageal pressure was also evaluated.

In group 1 the mean twitch pressure at the endotracheal tube on PEEP 0, 5 and 10 cmH2O was 5.2, 4.5 and 2.6 cmH2O: In group 2 this was significantly higher (15.1 cmH2O on PEEP 0 and 12.2 cmH2O on PEEP 5). A good correlation was found between twitch diaphragmatic pressure and twitch pressure at the endotracheal tube (r2=0.96) and between twitch oesophageal pressure and twitch pressure at the endotracheal tube (r2=0.98).

Patients with weaning failure have significantly lower twitch pressure at the endotracheal tube suggesting diaphragmatic dysfunction. Twitch pressure at the endotracheal tube may be a useful parameter to screen for diaphragmatic dysfunction in intubated critically ill patients. Further studies are needed to confirm these preliminary findings.
Transthoracic Echocardiography: Impact on Diagnosis and Management in Tertiary Care Intensive Care Units
Authors: Stanko L. K. , Jacobsohn E. , Tam J. W. , De Wet C. J. , Avidan M.
Published: January 2019

The purpose of this study was to evaluate the utility of transthoracic echocardiography (TTE) in an intensive care unit by determining its impact on diagnosis and management. Over a six-month time period, we performed a prospective observational study on all patients admitted to either the medical or the surgical intensive care unit. Structured interviews were conducted with referring physicians before and after the TTE to determine the referring physicians’ pre-TTE diagnosis, reasons for requesting the TTE, and whether the TTE resulted in a change in diagnosis and/or management. A total of 135 TTE examinations were done in 126 patients. The referring physicians deemed that clinical information was inadequate to make a definitive diagnosis and management plan in 36/135 (27%) of the requests. In 99/135 (73%) studies, physicians indicated that there was probably sufficient clinical information to formulate a diagnosis and management plan, but ordered a TTE to corroborate their clinical findings. Overall, a change in diagnosis occurred in 39/135 (29%) of studies, and a change in management in 55/135 (41%) of studies. Diagnosis was changed in 19/99 (19%) studies with adequate clinical data, and in 20/36 (56%) studies with inadequate clinical data (P<0.001). Management was changed in 34/99 (34%) of studies with adequate clinical data and in 21/36 (58%) of studies with inadequate clinical data (P=0.017). Of the 62 management changes, 57/62 (92%) changes were minor, and 5/62 (8%) were major. In conclusion we have found that TTE frequently resulted in a change in the diagnosis and management.
Seizures, Metabolic Acidosis and Coma Resulting from Acute Isoniazid Intoxication
Authors: Topcu I. , Yentur E. A. , Kefi A. , Ekici N. Z. , Sakarya M.
Published: January 2019

Isoniazid is an anti-tuberculosis drug, used commonly for treatment and prophylaxis of tuberculosis. Acute isoniazid intoxication is characterized by a clinical triad consisting of metabolic acidosis resistant to treatment with sodium bicarbonate, seizures which may be fatal and refractory to standard anticonvulsant therapy, and coma. Treatment requires admission to the intensive care unit for ventilatory support, management of seizures and metabolic acidosis. Pyridoxine, in a dose equivalent to the amount of isoniazid ingested, is the only effective antidote. We report the successful treatment of two isoniazid intoxication cases: the case of a child developing an accidental acute isoniazid intoxication and an adult case of isoniazid intoxication with the intent of suicide.
The Effects of Acute Fluid Loading on Plasma B-type Natriuretic Peptide Levels in a Septic Shock Patient
Authors: Mclean A. S. , Poh G. , Huang S. J.
Published: January 2019

A 64-year-old female patient was admitted to a general intensive care unit with sustained hypotension resulting from severe sepsis. Her admission plasma B-type natriuretic peptide was elevated (407 pg/ml), and echocardiogram displayed normal ventricular dimensions and function. The right ventricular end-diastolic diameter increased with acute fluid loading, and this coincided with a parallel increase in B-type natriuretic peptide. Subsequent fluid depletion was accompanied by a reduction in both right ventricular end-diastolic diameter and B-type natriuretic peptide. The present case indicates that acute fluid loading may alter plasma B-type natriuretic peptide levels, and highlights the importance of taking the clinical context into account when interpreting these levels.
Antibiotic Prescribing in Response to Bacterial Isolates in the Intensive Care Unit
Authors: Buising K. L. , Thursky K. A. , Bak N. , Skull S. , Street A. , Presneill J. J. , Cade J. F. , Brown G. V.
Published: January 2019

This study aimed to identify potential knowledge-performance gaps in antibiotic prescribing for bacterial isolates in the Intensive Care Unit (ICU) in order to guide the development of interventions such as antibiotic policies, decision support, and improved systems for communication between the laboratory and the bedside. A prospective observational cohort study of all patients admitted to a mixed medical/surgical ICU was undertaken over a six-month period in an Australian adult tertiary hospital. From a cohort of 524 patients, 108 had 303 isolates that were eligible for inclusion. Overall, 14.3% and 30.8% of sterile and non-sterile isolates respectively were associated with inadequate initial antibiotic therapy after identification of the bacteria. After sensitivity results were available inadequate directed therapy was observed in 4.0% and 21.3% of sterile and non-sterile isolates respectively. Problems were most commonly associated with isolates of Pseudomonas spp., Stenotrophomonas spp., Acinetobacter spp., S. aureus, enterococci and group III Enterobacteriaceae. Inadequate antibiotic therapy was found to be independently associated with prolonged length of ICU stay. Narrower spectrum antibiotic therapy was potentially available for 30% of isolates after sensitivity results were known. We conclude that there is scope to improve antibiotic prescribing in the ICU by providing clinicians with access to information regarding local susceptibility patterns and intrinsic resistance of bacteria, and spectra of antibiotic cover. Timely notification of laboratory results at the point of care may also facilitate improved prescribing performance.
Postoperative Pain Management following Bilateral Lung Volume Reduction Surgery for Severe Emphysema
Authors: Hooten W. M. , Karanikolas M. , Swarm R. , Huntoon M. A.
Published: January 2019

This study was conducted to audit the clinical management of a continuous local anaesthetic infusion delivered by a fluoroscopically placed thoracic epidural catheter in conjunction with supplemental intravenous opioid patient controlled analgesia for postoperative pain control following bilateral lung volume reduction surgery for severe emphysema. This retrospective case series involved a random sample of 43 patients from a possible 65 patients. The mean dose of epidural bupivacaine 0.15% was 6.7 ml/h (SD 1.5), while the mean daily dose of morphine or hydromorphone was 22.5 mg/day (SD 17.9) and 4.3 mg/day (SD 3.1), respectively. Inadequate analgesia was reported by 19 (44%) patients during the first two postoperative days, but was successfully treated by individual titration of these medications. The incidence of atrial fibrillation (n=6), premature epidural catheter dislodgement (n=6) or respiratory failure (n=3) appeared to be greater among patients who had inadequate analgesia at some stage. One patient developed excessive sedation; otherwise, there were no major complications. The use of an epidural bupivacaine infusion in conjunction with intravenous opioid patient controlled analgesia proved to be a safe and effective pain medication regimen when accompanied by individual titration of these agents in response to acute exacerbations of postoperative pain.
Anaesthesia in a Disaster Zone: A Report on the Experience of an Australian Medical Team in Banda Aceh following the ‘Boxing Day Tsunami’
Authors: Paix B. R. , Capps R. , Neumeister G. , Semple T.
Published: January 2019

We report on the experience of a 23-member Australian medical team in Banda Aceh, Indonesia, following the 2004 Boxing Day tsunami. Arriving 13 days after the tsunami that devastated the city, killed 100,000 of its inhabitants and injured thousands more, we carried out 130 surgical procedures in austere conditions over a 12-day period. Most surgery was peripheral, principally for plastic surgical or orthopaedic procedures to lower limb injuries. Intravenous ketamine anaesthesia was the technique of choice, with good surgical conditions and few significant side-effects.
An Audit of Morphine versus Fentanyl as an Adjunct to Ropivacaine 0.2% for High Thoracic Epidural Analgesia
Authors: Royse C. F. , Royse A. G. , Deelen D. A.
Published: January 2019

When used as an adjunct to local anaesthetic, opioid administered via the epidural route can improve the quality of analgesia. Reports of respiratory depression associated with epidural morphine use as a sole agent in the 1980s led to an increased use of lipophilic opioids, especially fentanyl. Although fentanyl is commonly used, controversy exists about its efficacy and site of action. It is possible that low-dose morphine may be more effective than fentanyl, without increasing the risk of respiratory depression.

A retrospective audit was conducted of 200 consecutive patients undergoing coronary artery bypass surgery who received high thoracic epidural analgesia.

One hundred patients who received fentanyl 2 μg/ml with 0.2% ropivacaine, prior to a change in our technique, were audited, followed by 100 patients who received 20 μg/ml morphine with 0.2% ropivacaine. Outcome measures included the incidence of Visual Analogue Score (VAS) ≥4/10; infusion rate adjustments; and side-effects. Patients receiving fentanyl were more likely to experience pain ≥4/10 (P'=0.002); the infusion rate was higher (P8=0.024); required more rate adjustments (P8=0.001); a greater need for noradrenaline (P'=0.001) and antiemetic drugs (P'=0.001). There were no significant differences between the groups for sedation scores or the incidence of respiratory depression.

This audit suggests morphine 20 μg/ml may be superior to fentanyl 2 μg/ml, as an adjunct to 0.2% ropivacaine. We found a reduced number of infusion interventions and less inadequate patient analgesia.
Ultrasound Guided Deep Cervical Plexus Block
Authors: Sandeman D. J. , Griffiths M. J. , Lennox A. F.
Published: January 2019

We describe a new technique for achieving a deep cervical plexus block using a portable vascular access ultrasound scanner (Site~Rite® II, Bard Access Systems, Pittsburgh, PA).
Failure of a Quality Improvement Process to Increase Nutrition Delivery to Intensive Care Patients
Authors: Ferrie S. , Mcwilliam D.
Published: January 2019

The importance of nutrition support in intensive care has been recognised, but many factors may limit successful provision of patients’ requirements. We conducted a twelve-month prospective audit, with intervention after six months, to determine whether longer-stay (>3 days) patients in our intensive care unit were receiving their nutritional requirements and to identify and improve factors limiting nutrition provision. Data was collected for 379 consecutive patients admitted to intensive care longer than three days. Total energy provided to each patient was recorded daily and compared with the predicted requirement. In the first six months, patients commenced nutrition 2.2±1.3 days after intensive care admission and were receiving 100% of predicted energy requirement by 4.8±3.3 days. Patients received nutrition on 82.3% of total patient-days, daily average 71.7% (43.2) of their energy requirement. Nutrition was interrupted on 30% of total patient-days. After six months, a Clinical Practice Improvement model was used to analyse reasons for inadequate feeding and introduce changes in practice. Main reasons for interruption included preparation for extubation and upper gastrointestinal intolerance. After intervention, interruptions due to these reasons were significantly reduced, however, no significant improvement was observed overall, either in the time to reach nutritional goals, or in the amount of energy received. Successful changes in practice, targeting only one or two main issues, can be overwhelmed by other factors. To effect significant improvement, a wider approach may be required.
Estimate of the Number of Patients Eligible for Treatment with Drotrecogin Alfa (Activated) Based on Differing International Indications: Post-hoc Analysis of an Inception Cohort Study in Australia and New Zealand
Authors: Finfer S. , Felton T. , Blundell A. , Lipman J. ,   The Anzics Clinical Trials Group Sepsis Investigators, Davies Andrew , MacArthur Colin , Newby Lynette , Bellomo Rinaldo , Wise Donna , Reece Graham , hawker Felicity , Soloveychik Lorisa , Nicholls James , Henderson Seton , Hunt Tamara , Bersten Andrew , Green David , Richards Brent , Green Stuart , Solano Tom , Flabouris Arthas , Joyce Chris , Limpus Anthony , Lipman Jeff , Turner Andrew , Finfer Simon , Szachin Vlad , Magnaye Maria , Dobb Geoff , MacKenzie Eileen , morris Gordon , Mitchell Imogen , van Heerden Vernon , Roberts Brigitte , O'leary Michael , Myburgh John , French Craig
Published: January 2019

We aimed to estimate the potential number of patients eligible for treatment with drotrecogin alfa (activated) when applying different international criteria.

The study was a post-hoc analysis of inception cohort study of 691 patients with severe sepsis during 5878 consecutive intensive care unit admission episodes in 23 closed multi-disciplinary ICUs of 21 hospitals (16 tertiary and 5 university-affiliated) in Australia and New Zealand. Outcomes assessed were presence of contraindications to treatment with drotrecogin alfa (activated), an admission APACHE II score of 25 or greater and dysfunction of two or more organs.

During 5878 consecutive intensive care admission episodes, 691 patients had severe sepsis, 553 (80.0%, 95% CI 77.0–83.0%) had no relative or absolute contraindication, 64 (9.3%, 7.1–11.4%)) had a relative contraindication and 74 (10.7%, 8.4–13.0%) had an absolute contraindication. Two hundred and six patients (3.5%, 3.0–4.0%) had an APACHE II score of 25 or greater, 452 (7.7%, 7.0–8.4%) had dysfunction of two or more organs, 469 (8.0%, 7.3–8.7%) had either dysfunction of two or more organs or an APACHE II score of 25 or greater.

Relatively few patients had an absolute contraindication to treatment with drotrecogin alfa (activated). Selection based on the APACHE II score results in fewer eligible patients than selection based on multiple organ dysfunction. Depending on the selection criteria used, for every hundred admissions to intensive care, between 3.5 and 8.0 of patients may be eligible for treatment with drotrecogin alfa (activated).
Quality of Life at Three Years after Cardiac Surgery: Relationship with Preoperative Status and Quality of Recovery
Authors: Myles P. S. , Viira D. , Hunt J. O.
Published: January 2019

A reduction in symptoms, increased longevity, and improved quality of life (QoL), are goals of cardiac surgery. We measured QoL in 108 adult cardiac surgical patients at about three years after cardiac surgery, and assessed the predictive ability of a 40-item quality of recovery (QoR-40) score. Our follow-up rate was 86% (n=93). When compared with preoperative status, QoL was improved at three years after surgery (P<0.0005). The dimensions of QoL that were most affected were physical functioning, role limitations due to physical problems, vitality, social functioning, and role limitations due to emotional problems (all P<0.005). There was a mild correlation between the day 3 QoR-40 and the three year SF-36, r=0.23 (P=0.029). There was a strong correlation between the three year QoR-40 and the three year SF-36, r=0.73 (P<0.0005). The QoR-40 and SF-36 done at three years after cardiac surgery demonstrated good internal consistency, QoR-40 α=0.86 (P<0.0005), SF-36 α=0.91 (P<0.0005). A poor quality recovery in the days after surgery can predict a poor QoL at three years after surgery. The QoR-40 is a valid and reliable measure of quality of recovery after surgery and anaesthesia. The QoR-40 is a useful, patient-oriented method of assessing recovery from anaesthesia and surgery.