bluuebunny/crossref_metadata_2025 huggingface dataset:
Most Nosocomial Pneumonias are Not Due to Nosocomial Bacteria in Ventilated Patients. Evaluation of the Accuracy of the 48 h Time Cut-off Using Carriage as the Gold Standard
Authors: Silvestri L. , Sarginson R. E. , Hughes J. , Milanese M. , Gregori D. , Van Saene H. K. F.
Published: January 2019

A prospective observational cohort study was undertaken with two endpoints: (1) to compare the time cut-off of 48h and the carrier state criterion for classifying lower airway infections in adult and paediatric long-term ventilated patients, and (2) to evaluate the potential of optimized time cut-offs for characterizing imported and ICU-acquired lower airway infections. All patients admitted to the general and paediatric intensive care units and expected to require mechanical ventilation for a period 3 days were enrolled. Surveillance cultures of throat and rectum were obtained on admission and thereafter twice weekly to distinguish micro-organisms that were imported into the unit from those acquired during the stay on the unit. A total of 130 adults and 400 children were studied. In the adult population, 70% of lower airway infections were classified as ICU-acquired by the 48 h cut-off and 48% by the criterion of carriage; on the paediatric ICU the percentages were 65% and 20%, respectively. To separate imported from ICU-acquired infections, eight days was optimal in the adult population and 10 days in the paediatric population. Sensitivity, specificity, positive predictive value and negative predictive value for a time cut-off of eight days for adults were 86, 77, 80, 83%, respectively, and using 10 days for children were 87, 62, 90, 56%, respectively. The use of the 48 h cut-off rule classifies patients as having nosocomial pneumonia, when in fact the infections are commonly caused by microorganisms carried in by the patients. In contrast, using the carriage method, the proportion of lung infections due to nosocomial bacteria was relatively small and was a late phenomenon. Although in prolonging the time cut-off the difference between the two types of classification was shorter, time cut-offs were still found to be unreliable for distinguishing imported from unit-acquired lower airway infections.
Prospective Independent Validation of APACHE III Models in an Australian Tertiary Adult Intensive Care Unit
Authors: Cook D. A. , Joyce C. J. , Barnett R. J. , Birgan S. P. , Playford H. , Cockings J. G. L. , Hurford R. W.
Published: January 2019

Evaluation of the performance of the APACHE III (Acute Physiology and Chronic Health Evaluation) ICU (intensive care unit) and hospital mortality models at the Princess Alexandra Hospital, Brisbane is reported. Prospective collection of demographic, diagnostic, physiological, laboratory, admission and discharge data of 5681 consecutive eligible admissions (1 January 1995 to 1 January 2000) was conducted at the Princess Alexandra Hospital, a metropolitan Australian tertiary referral medical/surgical adult ICU.

ROC (receiver operating characteristic) curve areas for the APACHE III ICU mortality and hospital mortality models demonstrated excellent discrimination. Observed ICU mortality (9.1%) was significantly overestimated by the APACHE III model adjusted for hospital characteristics (10.1%), but did not significantly differ from the prediction of the generic APACHE III model (8.6%). In contrast, observed hospital mortality (14.8%) agreed well with the prediction of the APACHE III model adjusted for hospital characteristics (14.6%), but was significantly underestimated by the unadjusted APACHE III model (13.2%). Calibration curves and goodness-of-fit analysis using Hosmer-Lemeshow statistics, demonstrated that calibration was good with the unadjusted APACHE III ICU mortality model, and the APACHE III hospital mortality model adjusted for hospital characteristics. Post hoc analysis revealed a declining annual SMR (standardized mortality rate) during the study period. This trend was present in each of the non-surgical, emergency and elective surgical diagnostic groups, and the change was temporally related to increased specialist staffing levels.

This study demonstrates that the APACHE III model performs well on independent assessment in an Australian hospital. Changes observed in annual SMR using such a validated model support an hypothesis of improved survival outcomes 1995–1999.
Ropivacaine 7.5 mg/ml versus Bupivacaine 5 mg/ml for Interscalene Brachial Plexus Block—A Comparative Study
Authors: Hofmann-Kiefer K. , Herbrich C. , Seebauer A. , Schwender D. , Peter K.
Published: January 2019

We investigated ropivacaine 7.5 mg/ml in comparison with bupivacaine 5 mg/ml in patients receiving interscalene brachial plexus block (ISB) and general anaesthesia.

In this randomized, double-blind, prospective clinical trial, each patient received an ISB block according to the technique originally described by Winnie36 and a catheter technique as per Meier12. The rapidity of onset and the quality of sensory and motor block were determined. After general anaesthesia had been induced further parameters evaluated were consumption of local anaesthetic, opioid and neuromuscular blocking drug. After arrival in the recovery room, the patients were assessed for intensity of pain using a visual analog scale (VAS).

One hundred and twenty patients were included in the study. The onset and development of sensory block was similar in both groups. Development and quality of motor block was also nearly identical for both local anaesthetics. Consumption of neuromuscular blocking drug and opioid did not differ between ropivacaine and bupivacaine. In the recovery room the mean pain score was less than 25 in both groups. There were no significant differences in terms of onset and quality of sensory or motor block during the intraoperative and early postoperative period. In addition we did not identify any side-effects related to the administration of the local anaesthetics.

Ropivacaine 7.5 mg/ml and bupivacaine 5mg/ml proved to be nearly indistinguishable when administered for interscalene brachial plexus block.
Survival following Mechanical Ventilation of Recipients of Bone Marrow Transplants and Peripheral Blood Stem Cell Transplants
Authors: Scott P. H. , Morgan T. J. , Durrant S. , Boots R. J.
Published: January 2019

Survival of bone marrow transplant recipients requiring mechanical ventilation is poor but improving. This study reports a retrospective audit of all haematopoietic stem cell transplant (HSCT) recipients requiring mechanical ventilation at an Australian institution over a period spanning 11 years from 1988 to 1998. Recipients of autologous transplants are significantly less likely to require mechanical ventilation than recipients of allogeneic transplants. Of 50 patients requiring mechanical ventilation, 28% survived to discharge from the intensive care unit, 20% to 30 days post-ventilation, 18% to discharge from hospital and 12% to six months post-ventilation. Risk factors for mortality in the HSCT recipient requiring mechanical ventilation include renal, hepatic and cardiovascular insufficiency and greater severity of illness. Mechanical ventilation of HSCT recipients should not be regarded as futile therapy.
Cerebrovascular Carbon Dioxide Reactivity in Sheep: Effect of Propofol or Isoflurane Anaesthesia
Authors: Myburgh J. A. , Upton R. N. , Ludbrook G. L. , Martinez A. , Grant C.
Published: January 2019

Propofol and isoflurane are commonly used in neuroanaesthesia. Some published data suggest that the use of these agents is associated with impaired cerebral blood flow/carbon dioxide (CO 2 ) reactivity. Cerebrovascular CO 2 reactivity was therefore measured in three cohorts of adult merino sheep: awake (n=6), anaesthetized with steady-state propofol (15 mg/min; n=6) and anaesthetized with 2% isoflurane (n=6). Changes in cerebral blood flow were measured continuously from changes in velocities of blood in the sagittal sinus via a Doppler probe. Alterations in the partial pressure of carbon dioxide in arterial blood (P a CO 2 ) over the range 18–63 mmHg were achieved by altering either the inspired CO 2 concentration or the rate of mechanical ventilation. Cerebral blood flow/CO 2 relationships were determined by linear regression analysis, with changes in cerebral blood flow expressed as a percentage of the value for a P a CO 2 of 35 mmHg. Propofol decreased cerebral blood flow by 55% relative to pre-anaesthesia values (P=0.0001), while isoflurane did not significantly alter cerebral blood flow (88.45% of baseline, P=0.39). Significant linear relationships between cerebral blood flow and CO 2 tension were determined in all individual studies (r 2 ranged from 0.72 to 0.99). The slopes of the lines were highly variable between individuals for the awake cohort (mean 4.73, 1.42–7.12, 95% CI). The slopes for the propofol (mean 2.67, 2.06–3.28, 95% CI) and isoflurane (mean 2.82, 2.19–3.45, 95% CI) cohorts were more predictable. However, there was no significant difference between these anaesthetic agents with respect to the CO 2 reactivity of cerebral blood flow.
Effect of Preoperative Oral Use of Erythromycin and Nizatidine on Gastric pH and Volume
Authors: Memis D. , Turan A. , Karamanlioglu B. , Guler T. , Yurdakoc A. , Pamukcu Z. , Turan N.
Published: January 2019

This randomized controlled trial examined the effects of preoperative oral erythromycin or nizatidine on gastric pH and volume. Sixty patients, ASA 1 and 2 status scheduled for elective surgery were studied. All subjects received oral study medication with 10 ml of water 60 minutes prior to surgery. Patients in Group 1 (n=20) were given erythromycin 200 mg, in Group 2 (n=20) nizatidine 300 mg, and in Group 3 (n=20) placebo capsule. A nasogastric tube was inserted immediately after anaesthesia induction. Gastric content was aspirated, and volume and pH recorded.

pH values determined in Group 1 were 5.6±1.87; in Group 2, 5.65±1.92 and in Group 3, 3.5±1.93. There was no statistical difference between Groups 1 and 2, but there was a statistically significant difference between Group 3 and Groups 1 and 2 (P<0.001). The volume of gastric content was 10.25±6.65 ml in Group 1, 10.3±6.29 ml in Group 2, and 20.25±16.72 ml in Group 3. Again, there was no statistical difference between Groups 1 and 2, but there was a statistically significant difference between Group 3 and Groups 1 and 2 (P<0.05). The proportion of patients considered “at risk” of significant lung injury should aspiration occur was 10% of Group 1, 5% of Group 2 and 20% of Group 3 (not statistically different).

We conclude that oral erythromycin and nizatidine given one hour prior to surgery are effective in reducing gastric pH and volume.
Suspected Malignant Hyperthermia Reactions in New Zealand
Authors: Pollock A. N. , Langton E. E. , Couchman K. , Stowell K. M. , Waddington M.
Published: January 2019

Early clinical signs, triggering agents, time to onset of reaction, mortality and methods of treatment were identified in 123 suspected malignant hyperthermia reactions. In vitro contracture test results were compared with clinical signs and the Malignant Hyperthermia Clinical Grading Scale. Increased end-tidal carbon dioxide is the earliest sign when not preceded by masseter spasm. Earlier diagnosis reduces the incidence of rigidity and severe metabolic acidosis. The combination of suxamethonium and a potent volatile anaesthetic agent triggers an earlier reaction compared with a volatile agent alone. There has been zero mortality since 1981, essentially due to a combination of advanced monitoring capability, increased anaesthetist awareness of malignant hyperthermia, and dantrolene availability.

DNA analysis has identified nine New Zealand families with ryanodine receptor gene mutations. A positive DNA test indicates malignant hyperthermia susceptibility with “causative” mutations but discordance requires that negative DNA tests are confirmed with in vitro contracture test. This test also demonstrated the shortcomings of the Malignant Hyperthermia Clinical Grading Scale.
The Effects of Inhalation of a Novel Nitric Oxide Donor, DETA/NO, in a Patient with Severe Hypoxaemia Due to Acute Respiratory Distress Syndrome
Authors: Lam C. F. , Van Heerden P. V. , Sviri S. , Roberts B. L. , Ilett K. F.
Published: January 2019

Aerosolized NONOates have been investigated in animal models in acute pulmonary hypertension, but none have been used in humans. We report the first use of aerosolized diethylenetriamine nitric oxide adduct (DETA/NO), a NONOate, in a patient with severe acute respiratory distress syndrome. Both pulmonary vascular resistance index and mean pulmonary arterial pressure were reduced by a mean of 26% and 18% respectively after the administration of a single dose of DETA/NO (150 μmol). Intrapulmonary shunting also improved. There were no significant changes in systemic arterial pressure or arterial methaemoglobin concentration after DETA/NO inhalation. We conclude that DETA/NO aerosol produced selective pulmonary vasodilation, with an improvement in pulmonary haemodynamics and oxygenation, while having no measurable effect on the systemic circulation.
The Use of Vasopressin to Treat Catecholamine-resistant Hypotension after Phaeochromocytoma Removal
Authors: Tan S. G. , Koay C. K. , Chan S. T.
Published: January 2019

A patient undergoing excision of phaeochromocytoma developed refractory hypotension which was complicated by significant intraoperative blood loss. Cardiovascular support with fluids, blood and noradrenaline failed to reverse the hypotension. Introduction of vasopressin successfully reversed the hypotension. The experience with this case suggests that vasopressin may be a useful adjunct in the treatment of catecholamine-resistant hypotension after phaeochromocytoma excision.
Evaluation of Induction Doses of Propofol: Comparison between Endstage Renal Disease and Normal Renal Function Patients
Authors: Goyal P. , Puri G. D. , Pandey C. K. , Srivastva S.
Published: January 2019

Anaemia, hypoproteinaemia and acidic pH in renal failure patients can alter the pharmacokinetics and pharmaco-dynamics of anaesthetic agents, resulting in altered dose requirements. We evaluated the induction dose of propofol in adult patients with end-stage renal disease by titrating the hypnotic effect by means of a clinical parameter as well as using a more objective assessment of hypnosis, the Bispectral Index (BIS) monitor. The dose was compared with that for patients with normal renal function. Propofol doses that provided the clinical end-point of hypnosis (syringe drop method), as well as the end-point of a mean (SD) BIS value of 50 (5), were evaluated in 27 end-stage renal disease and 27 normal renal function patients. Propofol was administered at 0.2mg/kg every 15 seconds until these end-points were achieved. End-stage renal disease patients required significantly higher propofol doses to achieve the clinical end-point of hypnosis (1.42 (0.24) mg/kg versus 0.89 (0.2) mg/kg in normal renal function patients, P<0.05 unpaired “t” test). Propofol dose required to achieve a BIS of 50 (5) was also higher in end-stage renal disease patients (2.03 (0.4) mg/kg versus 1.39 (0.43) mg/kg in normal renal function patients, P<0.05). There was a significant negative correlation of propofol dose with preoperative haemoglobin concentration. A hyperdynamic circulation in renal failure patients with anaemia may be responsible for the higher propofol dose requirement in this group.
Gum-elastic Bougie-guided Insertion of the ProSeal™ Laryngeal Mask Airway: A New Technique
Authors: Howath A. , Brimacombe J. , Keller C.
Published: January 2019

We determined the success rates, cardiovascular responses and airway morbidity for gum-elastic bougie-guided insertion of the ProSeal™ laryngeal mask airway. One hundred anaesthetized, non-paralyzed adults (ASA 1–2, aged 18 to 80 years) were studied. The ProSeal LMA drainage tube was primed with a well-lubricated 16 French gauge gum-elastic bougie with the curved end proximal and the straight end protruding 30 cm beyond the drainage tube tip. The straight end of the gum-elastic bougie was inserted into the oesophagus under laryngoscopic guidance, the laryngoscope removed and the ProSeal LMA inserted using the standard insertion technique and the gum-elastic bougie as a guide. The following variables were recorded: ease of insertion, oropharyngeal leak pressure, ventilatory capability, ease of gastric tube insertion, blood staining on the bougie or LMA at removal, and postoperative airway morbidity. Haemodynamic data were recorded immediately pre-insertion and every minute for five minutes after insertion. Gum-elastic bougie and ProSeal LMA insertion was successful at the first attempt in all patients within 50 seconds. There were no significant increases in heart rate or blood pressure. Oropharyngeal leak pressure was 33 (17–40) cmH 2 O and ventilation was possible without leak in all patients at 9.5 ml.kg –1 tidal volume. There were no drainage tube or gastric air leaks. Gastric tube insertion was successful at the first attempt in all patients. Blood staining at removal was not detected on the gum-elastic bougie, but was detected in 3% of ProSeal LMAs. The incidence of sore throat, dysphagia and dysarthria was 21%, 9% and 1% respectively. We conclude that gum-elastic bougie-guided insertion of the ProSeal LMA has a high success rate and is associated with minimal haemodynamic change and a low incidence of trauma.
The Impact of Intraoperative Transoesophageal Echocardiography on an Unselected Cardiac Surgical Population: A Review of 2343 Cases
Authors: Forrest A. P. , Lovelock N. D. , Hu J. M. , Fletcher S. N.
Published: January 2019

Although intraoperative transoesphageal echocardiography (TOE) has an established role in the management of some cardiac surgical procedures, there is little data on its impact on coronary artery bypass graft (CABG) cases that are stratified for clinical risk. This is a retrospective review of the surgical impact of intraoperative TOE on 2,343 unselected cardiac cases. The surgical impact of TOE findings were rated E (essential)—resulted in changes to the proposed surgical procedure or V (valuable)—the surgical technique for the planned surgery was altered. The surgical impact that routine TOE had on low-, medium- and high-risk CABG cases was also examined. The surgical impact of TOE for the total study population (E+V) was 4.5%. The impact was greatest in combined CABG + mitral valve procedures (18%). The impact in CABG cases was 3.5% overall, with an estimated impact in low-risk patients of 2.8% (95%CI. 2.7–3.0%) versus 6.7% (95% CI. 5.9–7.7%) in high-risk cases. The commonest E-impact in CABG patients was unscheduled valve surgery (2.6% of high-risk patients). The complication rate attributable to TOE was 0.09%. These findings provide indirect evidence for a potential patient benefit from the routine use of TOE in cardiac surgery.
The Influence of Methylene Blue Infusion on Cytokine Levels during Severe Sepsis
Authors: Memis D. , Karamanlioglu B. , Yuksel M. , Gemlik I. , Pamukcu Z.
Published: January 2019

The aim of our study was to assess the effect of methylene blue infusion on plasma levels of cytokines in severe sepsis.

In a prospective, randomized, double-blind, placebo-controlled study, patients received either methylene blue 0.5 mg.kg -1 .h -1 (MB group, n=15) or similar volume of isotonic saline (control group, n=15) IV for 6 hours. Plasma concentrations of tumour necrosis factor-α, interleukin-1, interleukin-2 receptor, interleukin-6, interleukin-8 were measured by sensitive immunoassays at basal (15 min before start of the study), immediately after, and at 24 and 48 hours after methylene blue infusion. We evaluated haemodynamic parameters (mean arterial pressure, heart rate), blood gases, methaemoglobin levels, and biochemical parameters at the same time.

Methylene blue administration had no significant effect on plasma cytokine levels, blood gases and biochemical parameters. When compared to placebo infusion in controls, methylene blue administration resulted in significantly higher mean arterial pressure (85±14 mmHg vs 74.1±10.3 mmHg; P<0.01), and methaemoglobin levels (1.06±0.22% vs 0.9±0.05%; P<0.05). Furthermore, comparison with baseline levels revealed significantly increased both mean arterial pressure (85±14 mmHg and 74.1±10.2 mmHg; P<0.05) and methaemoglobin levels (1.06±0.22% and 0.88±0.06%; P<0.05) in MB group. There was no difference in mortality rates between the groups.

We found that methylene blue infusion did not change cytokine levels or outcome in severe sepsis. The administration of methylene blue, however, resulted in a transient increase in arterial pressure. Because of the limited size of the present study, and the short period of observation, our findings need to be confirmed by larger clinical trials of methylene blue infused in a dose-titrated manner.
Use of Propofol Infusion in Australian and New Zealand Paediatric Intensive Care Units
Authors: Festa M. , Bowra J. , Schell D.
Published: January 2019

Despite the risk of propofol infusion syndrome, a rare but often fatal complication of propofol infusion in ventilated children and possibly adults, propofol infusion remains in use in paediatric intensive care units (PICU). This questionnaire study surveys the current pattern of use of this sedative infusion in Australian and New Zealand PICUs. Thirty-three of the 45 paediatric intensive care physicians surveyed (73%), from 12 of the 13 intensive care units, returned completed questionnaires. The majority of practitioners (82%) use propofol infusion in children in PICU, the main indication being for short-term sedation in children requiring procedures. 39% of respondents consider propofol infusion useful in ventilated children requiring longer-term sedation. 67% of paediatric intensivists use maximum infusion doses that may be considered dangerously high (≥10 mg/kg/h). Nineteen per cent use propofol infusion for prolonged periods (> 72 hours). A smaller proportion (15%) of respondents indicate that they may use both higher doses and prolonged periods of infusion, a practice likely to lead to a greater chance of serious adverse events. Knowledge of local protocols for the use of propofol infusion is associated with a significantly greater level of monitoring for possible adverse events. We suggest that national guidelines for the use of propofol infusion in children should be developed. These should include clear indications and contraindications to its use, a maximum dose rate and maximum period of infusion, with a ceiling placed on the cumulative dose given and clearly stated minimum monitoring requirements.
The Effect of an Alveolar Recruitment Strategy on Oxygenation during Laparascopic Cholecystectomy
Authors: Pang C. K. , Yap J. , Chen P. P.
Published: January 2019

This prospective randomized controlled trial examined the effect of an “alveolar recruitment strategy” (ARS) in healthy patients having laparoscopic cholecystectomy.

Twenty-four consecutive ASA 1 or 2 patients were randomly allocated to an ARS or control group. All patients were manually ventilated to a maximal airway pressure of 25 to 30 cmH 2 O or a tidal volume of 10 ml/kg during induction of general anaesthesia. After intubation, the control group was ventilated with standardized mechanical ventilation settings. The ARS group was manually ventilated to an airway pressure of 40 cmH 2 O for 10 breaths over one minute, followed by mechanical ventilation with similar standardized settings plus 5 cmH 2 0 positive end-expiratory pressure. Blood pressure, heart rate, arterial oxygen and carbon dioxide tension (PaO 2 and PaCO 2 ) was measured pre-induction, 20 minutes post induction but before abdominal insufflation, 20 minutes after abdominal insufflation, and 20 minutes after arrival in the recovery room.

Demographic and operation data were similar. The ARS group pre-insufflation PaO 2 [30.16 (9.43)] was higher than the control group [22.19 (9.08)] (P=0.047). There was a significant difference in PaO 2 between the ARS [23.94 (4.87)] and control [17.26 (3.93)] groups during the post-insufflation period (P=0.001). There were no significant differences in PaO 2 between the groups during baseline and recovery periods. No adverse effects were reported.

ARS improved arterial oxygenation intraoperatively in healthy patients having laparoscopic cholecystectomy, without clinical cardiovascular compromise or respiratory complication. We conclude that this alveolar recruitment strategy is a useful method of increasing arterial oxygenation.
The Use of Modified VBM Laryngeal Tube Compared to Laryngeal Mask Airway during Spontaneous Ventilation
Authors: Chiu C. L. , Murugasu J. , Chan L.
Published: January 2019

We have compared the use of the laryngeal mask airway with the new modified laryngeal tube in a prospective randomized controlled study. Sixty ASA 1 or 2 patients, aged 18 to 65 years, scheduled for elective surgery and breathing spontaneously under general anaesthesia, were studied. After preoxygenation, anaesthesia was induced with fentanyl and propofol. The patients were randomized to receive either a laryngeal mask airway or a laryngeal tube. Anaesthesia was maintained with nitrous oxide, oxygen and isoflurane. We recorded the speed and the ease of insertion, the number of attempts needed to successfully secure the airway and intraoperative complications, such as partial airway obstruction needing airway manipulation. The airway devices were removed with the patients fully awake at the end of surgery. Systolic arterial blood pressure, heart rate and end-tidal CO 2 were recorded at various time intervals. Postoperative complications were recorded. We found that the incidence of partial airway obstruction needing intraoperative airway manipulation was higher with the laryngeal tube than with the laryngeal mask airway. We conclude that during spontaneous ventilation the modified laryngeal tube is not as reliable in providing a satisfactory airway and we consider it is not a suitable alternative to the laryngeal mask airway.
Volatile Agents to Avoid Ventilating Asthmatics
Authors: Baigel G.
Published: January 2019

The management of six awake, spontaneously breathing patients with acute severe asthma who responded to a subanesthetic dose of an inhalational agent is described. All of these patients were on maximal medical treatment, the next intervention likely to be tracheal intubation and mechanical ventilation in the face of further deterioration. All six patients initially responded dramatically, although one required mechanical ventilation after initial response.
Combination of Adenosine with Prilocaine and Lignocaine for Brachial Plexus Block Does not Prolong Postoperative Analgesia
Authors: Apan A. , Basar H. , Ozcan S. , Buyukkocak U.
Published: January 2019

Adenosine analogues have been used by subarachnoid injection for the treatment of inflammatory and neuropathic pain. There are no data on the use of adenosine in peripheral nerve blocks. The aim of the present study was to determine the analgesic efficacy of adenosine in combination with a local anaesthetic solution for brachial plexus (BP) block.

With local ethics committee approval, 50 consenting adult patients undergoing upper limb surgery were enrolled in this double-blind, prospective, randomized study. Patients with a history of bronchospastic disease were excluded. Patients were instructed not to take theophylline-containing drugs and beverages for at least one day before surgery or on the first postoperative day. A supraclavicular BP block was performed by injecting a mixture totalling 35 ml made up of prilocaine 1% 10 ml and lignocaine 2% 20 ml with adrenaline 1:200 000, and adenosine 10 mg in 5 ml saline (Group 1) or 5 ml saline (Group 2) as a placebo control group. Postoperative analgesia was assessed by time to first rescue analgesia, analgesic consumption in the first 24 hours, and VAS at rest at 4, 8, 12, 16, 20 and 24 hours. Side-effects were also noted.

Vital signs were stable in both groups throughout the operation. There were no significant differences between the groups in onset of motor and sensory block. Time to first pain sensation from block was not significantly longer in the adenosine group (379±336 min) compared with controls (304±249 min, mean±SD, P=0.14). Time to first analgesic requirements and analgesic consumption in the first 24 hours were also similar in both study groups.

In the present study, the addition of adenosine to local anaesthetic in brachial plexus block did not significantly extend the duration of analgesia.
The Influence of a Blood Conserving Device on Anaemia in Intensive Care Patients
Authors: Macisaac C. M. , Presneill J. J. , Boyce C. A. , Byron K. L. , Cade J. F.
Published: January 2019

The contribution of iatrogenic blood loss through diagnostic testing to the anaemia of critical illness remains controversial. We measured the effect of an arterial line blood conservation device upon blood loss and anaemia in adult intensive care patients.

This randomized controlled trial of 160 patients in a major Intensive Care Unit (ICU) compared a blood conservation device (Venous Arterial Blood Management Protection Plus, VAMP Plus system, Baxter Healthcare) (VAMP group) to a standard arterial pressure line set attached to an arterial catheter (control group). The primary outcome measured was the change in haemoglobin concentration (Hb) during each patient's ICU admission and the volume of blood lost through diagnostic testing in ICU was also recorded.

Both groups of 80 patients were matched for age, gender, severity of illness (APACHE II), baseline Hb on entry and ICU length of stay. Both groups had a similar (median [range]) change in Hb during ICU admission (VAMP-7 [- 84 to+21] g/l; Control -4 [-67 to+40] g/l; P=0.33). The VAMP patients lost significantly less blood for diagnostic testing while in ICU (VAMP 63 [0 to 787] ml; Control 133 [7 to 1227] ml; P=0.001).

We conclude that the VAMP Plus system significantly reduced iatrogenic blood loss in critically ill patients, but this reduction did not affect the fall in Hb that accompanies critical illness.
Bispectral Index during Modified Rapid Sequence Induction Using Thiopentone or Propofol and Rocuronium
Authors: Sie M. Y. , Goh P. K. , Chan L. , Ong S. Y.
Published: January 2019

This randomized controlled trial compared Bispectral Index (BIS) values in 40 patients after a modified rapid sequence induction using thiopentone 4 mg/kg or propofol 2 mg/kg with rocuronium 0.6 mg/kg as muscle relaxant. Endotracheal intubation was performed at 60 seconds from induction of anaesthesia and BIS values were recorded for three minutes after induction. At the 120, 150 and 180 second measurements there was a significantly greater proportion of subjects with BIS values ≤ 60 (“anaesthetized”) in the propofol group compared with the thiopentone group (P values <0.02, <0.01 and <0.01 respectively).

All intubations were completed within two minutes. No explicit recall of intubation was detected clinically with either induction agent. The BIS scores we have measured suggest that thiopentone 4 mg/kg is more likely to be associated with lighter planes of anaesthesia and consequent risk of awareness than propofol 2 mg/kg, if intubation is delayed or prolonged.
Does the Provision of Pre-prepared Morphine Solution Alter the Administration of Opioids to Patients in the Recovery Room?
Authors: Reeves M.
Published: January 2019

The provision of immediate postoperative analgesia using titrated intravenous opioid is widespread. Protocols requiring two nurses to sign out, check and draw up opioid solutions are time-consuming and might act as a bar to the prompt provision of analgesia. One hundred and five patients were randomly assigned to one of three groups. Prepared morphine solution 10 mg (Group Ten) or 5 mg (Group Five) or no syringe (Group Zero) accompanied the patient to the post anaesthesia care unit. Nursing staffs were unaware of the trial. The likelihood of receiving morphine was actually higher in Group Zero than in Groups Five and Ten but not significantly different (relative risk 1.4, 95% confidence intervals 0.8-2.4). The dose of morphine administered was not significantly different between the groups. Provision of pre-prepared opioid solution did not increase either the frequency of morphine administration or the dose in this study.
Medicolegal Claims against Anaesthetists: A 20 Year Study
Authors: Cass N. M.
Published: January 2019

A total of 222 medicolegal claims involving 160 anaesthetist members of Victoria's largest medical indemnity organization during the period 1980 to 1999 are reported, with 35% of anaesthetists having a claim. There were 49 claims in the fist decade and 173 in the second, with 84 related to dental injury being predominant. Other common causes of claims were awareness, epidural anaesthesia, coronial enquiries, nerve palsies, postoperative complications and circulatory arrest. Anaesthetists were joined with surgeons in 17 claims. The average delay between the incident and the resolution of the claim was 11 months for dental claims and 46 months for non-dental ones.
Comparison of a Radiant Patient Warming Device with Forced Air Warming during Laparoscopic Cholecystectomy
Authors: Wong A. , Walker S. , Bradley M.
Published: January 2019

The importance of maintaining a patient's core body temperature during anaesthesia to reduce the incidence of postoperative complications has been well documented. The standard practice of this institution is the use of a forced air device for intraoperative warming. The purpose of this study was to compare this standard with an alternative warming device using a radiant heat source which only heated the face.

This prospective, randomized controlled trial compared the efficacy of two methods of intraoperative warming: the BairHugger™ (Augustine Medical, U.S.A.) forced air device and the SunTouch™ (Fisher & Paykel Healthcare, N.Z.) radiant warmer during laparoscopic cholecystectomy in 42 female patients. Oesophageal core temperatures were recorded automatically on to computer during operations using standardised anaesthesia, intravenous infusions and draping.

The study failed to show any statistical or clinical difference between the two patient groups in terms of mean core temperature both intraoperatively (P=0.42) and in the recovery period (P=0.54). Mean start to end core temperature differences were marginly lower in the radiant group (0.08°C) but not statistically or clinically significantly different.

Given some of the drawbacks with forced air systems, such as the expense of the single use blanket, this new radiant warming device offers an alternative method of active warming with advantages in terms of cost and possible application to a wide variety of surgical procedures.
Rupture of Left Main Bronchus Associated with Radiotherapy-induced Bronchial Injury and Use of a Double-lumen Tube in Oesophageal Cancer Surgery
Authors: Jha R. R. , Mishra S. , Bhatnagar S.
Published: January 2019

We report a case of rupture of the left main bronchus in a female patient with oesophageal carcinoma, who had received thoracic radiotherapy preoperatively. Endotracheal intubation was achieved with a left-sided double-lumen tube. After almost three hours of intubation and one and half hours of one-lung ventilation, bronchial injury was detected. Immediate surgical repair of the membranous part of the bronchus was undertaken, as well as completion of the oesophagectomy. Radiotherapy-induced damage to the bronchus was thought to have contributed to the rupture. The presentation, diagnosis and management of intraoperative bronchial rupture are discussed.
Avoidance of Laser Ignition of Endotracheal Tubes by Wrapping in Aluminium Foil Tape
Authors: Walker P. , Temperley A. , Thelfo S. , Hazelgrove A.
Published: January 2019

A 12-month-old child with a history of prematurity, severe respiratory compromise and failure to thrive required laser supraglottoplasty for severe laryngotracheobronchomalacia. Maintaining adequate oxygenation intraoperatively proved very difficult. Our usual technique with no endotracheal tube was not possible and CO 2 lasering was commenced with a polyvinylchloride endotracheal tube in the operative field. The endotracheal tube was struck by the laser but did not ignite. Concern about the very serious morbidity from a laser-induced fire in the airway prompted a search for possible solutions. No commercially available laser-resistant tube is available in small enough diameter to use in an infant. An aluminium foil tape (3M #425) was evaluated and found to be potentially very useful to protect against an airway fire in this uncommon situation.
Intubation Conditions following Rocuronium: Influence of Induction Agent and Priming
Authors: Leykin Y. , Pellis T. , Lucca M. , Gullo A.
Published: January 2019

A small priming dose of rocuronium can shorten the onset time of neuromuscular blockade. Induction agents with less cardiovascular depression also reduce the onset time. We hypothesized that ketamine, compared to thiopentone, would reduce onset time and improve intubating conditions following priming. Sixty patients ASA I to II, randomized by computer-generated sequence to four groups were investigated in a double-blind controlled trial. In the two groups with priming, 0.04 mg/kg of rocuronium was followed by three minutes of priming interval. Induction was followed by an intubation dose of 0.4 mg/kg of rocuronium. After 30 seconds, intubation was attempted within a further 20 seconds. In the two control groups, the same sequence was repeated except sham priming (saline) was given. For induction, S-ketamine (1 mg/kg) or thiopentone (4 mg/kg) were administered. Intubating conditions were graded as excellent, good, poor, or not possible. Neuromuscular transmission was monitored by acceleromyography of the thumb. There were no measured differences in onset time of neuromuscular block or in haemodynamics between the groups. The proportion of good to excellent intubating conditions was higher when ketamine was preceded by priming compared to ketamine without priming (87% vs 20%; P<0.05). In both priming and control groups intubating conditions were improved when using ketamine compared to thiopentone (P<0.05). The mechanism of this effect was not clear from this study.
How Well Can Anaesthetists Discriminate Pulse Oximeter Tones?
Authors: Morris R. W. , Mohacsi P. J.
Published: January 2019

The ability of experienced anaesthetists to discern oxygen saturation by listening to the tones of a Datex AS3 pulse oximeter was examined. Five-second samples were recorded using a high fidelity patient simulator and replayed singly and in pairs. Whilst the lower saturations were generally recognized as lower, the perceived range was greatly compressed. Median perceived estimates for 70% saturation was 89%, for 80% was 93% and for 94% was 94%. When comparing pairs of samples, the direction of the difference was correctly discerned by 70% of anaesthetists for differences of 2%, rising to 95% for differences of greater than 8% oxygen saturation. The magnitude of the difference was consistently underestimated. With an actual difference of 20%, the median estimate was 5%. The results indicate that while qualitative estimate changes in oxygen saturation are moderately reliable, quantitative estimation is severely limited by a compromised perceived scale. This may lead to underestimation of the severity if the auditory signal is relied on in isolation. A non-linear (musical) scale may prove more appropriate and should be investigated. Testing experienced anaesthetists demonstrated that most could detect the direction, but not the magnitude of a change in saturation by listening to the change in pitch of a Datex AS3 pulse oximeter tone.
Serum Erythropoietin Levels in Septic Shock
Authors: Tamion F. , Le Cam-Duchez V. , Menard J. F. , Girault C. , Coquerel A. , Bonmarchand G.
Published: January 2019

Erythropoietin is a glycoprotein hormone mainly released by the kidney, which stimulates red blood cell production. However, in sepsis, the mechanisms responsible for the final increase in circulating erythropoietin remain unclear. Seventeen critically ill patients with Simplified Acute Physiologic Score average 66 (range 43 to 103) were included in this study. Ten patients survived and seven died within 28 days. Blood samples obtained at different times were assayed for erythropoietin, cytokine levels and lactate measurements. PCO2 gap was assessed to detect the presence of gastric mucosal acidosis. Erythropoietin decreased in the patients who survived while it remained high or increased in non-survivors (37±6.5 vs 147±6.7 UI/l respectively, P<0.05). Erythropoietin plasma levels were correlated with IL-6 levels (r=0.84, P<0.05) and TNFa levels (r=0.84, P<0.05). We observed a significant positive relationship between erythropoietin plasma levels and lactate concentrations (r=0.89, P<0.05) and with PCO2 gap (r=0.9, P<0.05). No correlation was found between erythropoietin concentration and the other parameters. High serum erythropoietin levels in non-survivors were observed with septic shock despite an increase in the levels of proinflammatory cytokines. We found a relationship between erythropoietin concentration and biological markers of tissue hypoperfusion i.e. lactate levels or PCO2 gap. This relationship could suggest tissue hypoperfusion as the stimulating factor for erythropoietin production in septic shock.
Commercial Low-citrate Anticoagulation Haemofiltration in High Risk Patients with Frequent Filter Clotting
Authors: Naka T. , Egi M. , Bellomo R. , Cole L. , French C. , Botha J. , Wan L. , Fealy N. , Baldwin I.
Published: January 2019

This study assessed the safety and efficacy of a commercial low-citrate concentration-based pre-filter replacement fluid during continuous veno-venous haemofiltration (CVVH) in patients with frequent filter clotting and high risk of bleeding. We used a commercial low-citrate fluid as pre-dilution replacement fluid during CVVH (citrate: 11 mmol/l (33 meq/l), sodium: 140 mmol/l, chloride: 108 mmol/l and potassium: 1 mmol/l). A calcium and magnesium infusion was delivered separately by central line for the maintenance of serum ionized calcium (Cai) and total magnesium (Mg). In this prospective observational study, 30 patients, 124 filters and 1,515 treatment-hours were observed. Median filter life of citrate CVVH was 9.5 hours. Filter life in the 48 hours prior to citrate CVVH was also observed. In the patients on prior non-anticoagulant CVVH (n=14) filter life increased significantly with citrate (9.5 hours vs 5 hours; P<0.0001). In patients on prior heparin CVVH (n=15), filter life was similar with citrate (10 hours vs 8 hours; P=0.68). However, in patients with prior early/frequent filter clotting despite heparin (n=11) filter life increased significantly (10 hours vs 7 hours; P=0.038). Of 411 serum Cai measurements, none showed a Cai<0.85 mmol/l and, of 84 observations, none showed a serum Mg<0.6mmol/l. One patient with sepsis and shock needed to cease citrate CVVH because of progressive ionized hypocalcaemia and increasing anion gap. No other adverse effects were observed. In selected patients, CVVH with a commercial low-citrate concentration solution as pre-filter replacement fluid and a simultaneous calcium and magnesium infusion protocol appears generally safe. Filter life was acceptable and superior to that achieved with previous treatment.
Anaesthetic Mortality Rates in Western Australia 1980–2002
Authors: Gibbs N. , Rodoreda P.
Published: January 2019

The Western Australian Anaesthetic Mortality Committee has collected data since 1980. During this time, reporting of anaesthesia mortality has been mandatory in Western Australia, confidentiality and legal protection have been ensured, consistent definitions and classifications have been used, and reasonable estimates have been available for the number of surgical procedures performed. The data indicate that there was a decrease in anaesthesia-related mortality in the mid 1980s. Since then the rates have been relatively stable, in relation to both population and number of surgical procedures performed. At present, the rates are extremely low (<1:50,000 surgical procedures per annum), and similar to rates reported from other Australian states. While these figures are encouraging, their main function is to serve as the baseline for further improvements.
The Neurotoxic Effects of Intrathecal Midazolam and Neostigmine in Rabbits
Authors: Demirel E. , Ugur H. C. , Dolgun H. , Kahilogullari G. , Sargon M. F. , Egemen N. , Kecik Y.
Published: January 2019

In parallel with improvements in understanding pain neurophysiology, many chemicals have recently been investigated for spinal anaesthesia and analgesia. However, studies discussing the effects of these drugs on neural tissue indicate that knowledge about some aspects of neurotoxicity is limited. Forty-nine New Zealand albino rabbits, weighing 2.2±0.2 kg, were randomly assigned to seven groups of seven animals each. Single dose groups received intrathecally through the atlantooccipital membrane 0.9% saline 1.5 ml; midazolam 100 μg/kg (low dose midazolam group) or 500 μg/kg (high dose midazolam group); neostigmine 10 μg/kg (low dose neostigmine group) or 50 μg/kg (high dose neostigmine group). Two groups had seven days of repeated dosing with either midazolam 100 μg/kg/day (repeat midazolam group) or 10 μg/kg/day neostigmine (repeat neostigmine group). The animals were sacrificed on day 8, and two spinal cord sections from the fourth cervical level and fourth lumbar level were removed and prepared for histopathological study. Transmission electron microscopic evaluations were performed on transverse spinal cord sections by a neuropathologist blinded to the group allocation. Twenty myelinated axons and neurones in the cervical and lumbar sections were investigated for the histopathological study. This study indicates that midazolam and neostigmine have different neurotoxic effects that depend on the dose and the repetition of dosing when these drugs are administered intrathecally.
Methods to Assess Performance of Models Estimating Risk of Death in Intensive Care Patients: A Review
Authors: Cook D. A.
Published: January 2019

Models that estimate the probability of death of intensive care unit patients can be used to stratify patients according to the severity of their condition and to control for casemix and severity of illness. These models have been used for risk adjustment in quality monitoring, administration, management and research and as an aid to clinical decision making. Models such as the Mortality Prediction Model family, SAPS II, APACHE II, APACHE III and the organ system failure models provide estimates of the probability of in-hospital death of ICU patients.

This review examines methods to assess the performance of these models. The key attributes of a model are discrimination (the accuracy of the ranking in order of probability of death) and calibration (the extent to which the model's prediction of probability of death reflects the true risk of death). These attributes should be assessed in existing models that predict the probability of patient mortality, and in any subsequent model that is developed for the purposes of estimating these probabilities.

The literature contains a range of approaches for assessment which are reviewed and a survey of the methodologies used in studies of intensive care mortality models is presented. The systematic approach used by Standards for Reporting Diagnostic Accuracy provides a framework to incorporate these theoretical considerations of model assessment and recommendations are made for evaluation and presentation of the performance of models that estimate the probability of death of intensive care patients.