bluuebunny/crossref_metadata_2025 huggingface dataset:
Practice Environment Scale of the Nursing Work Index: A Reliability Generalization Meta-Analysis
Authors: Zangaro George A. , Jones Kimmith
Published: January 2019

A healthy work environment is a critical factor in nurse satisfaction, retention, and patient outcomes. The Practice Environment Scale of the Nursing Work Index (PES-NWI) is the most commonly used instrument to measure the nursing practice environment. This study uses meta-analysis to examine the reliability generalization of the PES-NWI. A meta-analysis of 51 studies representing a total of 80,563 subjects was conducted. The mean score reliability for the PES-NWI based on 38 studies ( n = 68,278) was .922 ( p < .05). The Mean Weighted Effect Size was stronger for studies conducted in the United States versus non-U.S. (.946 vs. .907). For studies rated high and moderate quality, the mean score reliability was .911 and .946, respectively. Scores on the PES-NWI are reliable for measuring the nursing practice environment across samples in the United States and non-U.S. countries.
Children with Cleft Palate: Predictors of Otologic Issues in the First 10 Years
Authors: Funamura Jamie L. , Lee Janet W. , McKinney Samantha , Bayoumi Ahmed G. , Senders Craig W. , Tollefson Travis T.
Published: January 2019

Objective

To evaluate the characteristics of children with cleft palate associated with persistent otologic issues in the first 10 years of life.

Study Design

Case series with chart review.

Setting

Single academic center.

Subjects and Methods

Children born with cleft palate from 2003 to 2007 and treated by the UC Davis Cleft and Craniofacial Team between January 2003 and December 2017 were included in the study. Data from 143 patients were analyzed via Wilcoxon rank sum and Fisher exact tests for univariate analysis and logistic regression to determine adjusted odds ratios.

Results

The median length of follow‐up was 9.9 years, and the age at last ear examination was 10.7 years. At the last evaluation, unresolved otologic issues were common, with at least 1 ear having a tympanic membrane (TM) perforation (16.1%), a tympanostomy tube (36.2%), or conductive hearing loss (23.1%). After adjusting for demographic and clinical characteristics, history of palate revision or speech surgery was associated with having a TM perforation (P =. 02). The only clinical variables associated with conductive hearing loss was the presence of a TM perforation (P <. 01) or a genetic abnormality (P =. 02). Severity of palatal clefting was not associated with specific otologic or audiologic outcomes after adjusting for other characteristics.

Conclusion

A large proportion of children with cleft palate have persistent otologic issues at age 10 years and would benefit from continued close monitoring well after the age when most children have normalized eustachian tube function. Prolonged otologic issues were not found to be associated with cleft type.
Effect of Adenotonsillectomy on Ambulatory Blood Pressure in Pediatric Obstructive Sleep Apnea: 6‐Month Follow‐up Study
Authors: Kang Kun‐Tai , Chiu Shuenn‐Nan , Lin Che‐Yi , Weng Wen‐Chin , Lee Pei‐Lin , Hsu Wei‐Chung
Published: January 2019

Objective

To investigate 24‐hour ambulatory blood pressure changes 6 months after surgery among children with obstructive sleep apnea.

Study Design

Prospective interventional study.

Setting

Tertiary medical hospital.

Subjects and Methods

Children aged 4 to 16 years with symptoms of obstructive sleep apnea (apnea‐hypopnea index >1) were recruited. All children underwent adenotonsillectomy and postoperative polysomnography overnight. The 24‐hour ambulatory blood pressure was measured before and 6 months after surgery.

Results

The study cohort enrolled 124 children: mean (SD) age, 7.3 (3.1) years; 73% boys. After surgery, the apnea‐hypopnea index significantly decreased from 13.3 (18.1) to 3.3 (7.2) events per hour (P <. 001). Overall systolic blood pressure and diastolic blood pressure were not significantly different following surgery, while daytime systolic blood pressure was slightly increased (114.3 to 117.3 mm Hg, P <. 01) postoperatively. The hypertensive group (n = 43) exhibited significantly decreased levels of overall diastolic, nighttime systolic, and nighttime diastolic blood pressure (P <. 05), and 54% of hypertensive children became nonhypertensive after surgery. The nonhypertensive group (n = 81) showed slightly increased levels of nocturnal overall systolic, daytime systolic, and nighttime systolic blood pressure. A generalized linear mixed model revealed that children with hypertension had a greater decrease in systolic and diastolic ambulatory blood pressure during the daytime and nighttime (all P <. 05) than those without hypertension.

Conclusions

Ambulatory blood pressure changes after adenotonsillectomy among children with obstructive sleep apnea are minimal. The decrease in ambulatory blood pressure after surgery is more prominent for hypertensive children than nonhypertensive children.
An Investigation of the Early Effects of Manual Lung Hyperinflation in Critically Ill Patients
Authors: Hodgson C. , Denehy L. , Ntoumenopoulos G. , Santamaria J. , Carroll S.
Published: January 2019

This prospective within-group multicentre study was designed to assess the safety and short-term effectiveness of manual lung hyperinflation in mechanically ventilated patients. Eighteen patients from the intensive care units of two tertiary institutions were included and acted as their own control. Manual lung hyperinflation treatment involved patient positioning (side-lying), suctioning and manual lung hyperinflation. Side-lying treatment involved patient positioning and suctioning alone. Patients received both treatments on the day of data collection. Results demonstrated significant improvement for static respiratory system compliance (P=0.001) with manual lung hyperinflation treatment compared to side-lying treatment. Manual lung hyperinflation treatment also cleared a significantly greater wet weight of sputum (P=0.039). There were no differences between manual lung hyperinflation and side-lying treatment for gas exchange (Pao2/FIO2 and Paco2), mean arterial pressure or heart rate. In conclusion, total static respiratory system compliance and sputum clearance were improved by the addition of manual hyperinflation to a physiotherapy treatment of positioning and suctioning in mechanically ventilated patients without compromise to cardiovascular stability or gas exchange.
Measurement of Quality of Recovery in 5672 Patients after Anaesthesia and Surgery
Authors: Myles P. S. , Reeves M. D. S. , Anderson H. , Weeks A. M.
Published: January 2019

Quality of recovery after an operation is an important dimension of the patient's experience and may be related to the quality of anaesthesia care. Satisfaction with anaesthesia is a vital component of quality care but difficult to measure. We examined our database of 5672 adult patients to determine if quality of recovery is associated with satisfaction with anaesthesia and to identify the perioperative factors that might influence both these outcome measures. We found that a nine-item quality of recovery score (“QoR Score”) was related to satisfaction with anaesthesia (P<0.0005): the overall level of satisfaction was high (97.2%; median QoR Score 16); 106 patients (2.1%; median QoR Score 14) were “somewhat dissatisfied” and 32 patients (0.6%; median QoR Score 13) were “dissatisfied” with their anaesthesia care. Patients who experienced any of a number of perioperative complications had lower QoR Scores (P<0.0005). We have further demonstrated the validity and clinical utility of the QoR Score, and in particular, its relationship to patient satisfaction in adult surgical patients.
Acyclovir Induced Coma in the Intensive Care Unit
Authors: Rajan G. R. C. , Cobb J. P. , Reiss C. K.
Published: January 2019

A 73-year-old man with multiorgan failure requiring mechanical ventilation and haemodialysis developed herpes labialis infection during his stay in the ICU. This was treated with enteral acyclovir. He developed persistent neurologic impairment soon after acyclovir administration, which, over the course of seven days, progressed to coma, the aetiology of which was unclear. The computed tomograph (CT) of the brain and the cerebrospinal fluid (CSF) examination was normal. The electroencephalogram (EEG) showed generalized slowing. The possibility of acyclovir neurotoxicity was considered and the drug was discontinued. Haemodialysis was instituted and the patient made a complete neurological recovery. We believe that this is the first reported case of coma due to enteral acyclovir.
Target-Controlled Intravenous Anaesthesia with Bispectral Index Monitoring for Thoracotomy in a Patient with Severely Impaired Left Ventricular Function
Authors: Leonard I. E. , Myles P. S.
Published: January 2019

The anaesthetic management of an elderly patient with severely impaired left ventricular function undergoing thoracotomy and lobectomy is described. Total intravenous anaesthesia (TIVA) with remifentanil and target-controlled infusion of propofol titrated according to the bispectral index (BIS) was used, with thoracic epidural anaesthesia commenced at the end of surgery providing postoperative analgesia. Avoidance of intraoperative epidural local anaesthetics and careful titration and dose reduction of propofol using the BIS was associated with excellent haemodynamic stability. The rapid offset of action of remifentanil and low-dose propofol facilitated early recovery and tracheal extubation. The BIS was a valuable monitor in optimal titration of TIVA.
Oesophageal Rupture in a Patient with Postoperative Nausea and Vomiting
Authors: Baric A.
Published: January 2019

Rupture of the oesophagus (Boerhaave's syndrome) is a rare complication of forceful or suppressed vomiting. Postoperative nausea and vomiting is common but does not usually lead to life-threatening complications. A case of oesophageal rupture in a man who experienced postoperative nausea and vomiting after an uncomplicated procedure is described in this report. Delayed diagnosis mandated conservative treatment. The clinical presentation, diagnosis and management of oesophageal rupture is discussed.
Electroencephalographic Indices Related to Hypnosis and Amnesia during Propofol Anaesthesia for Cardioversion
Authors: Baker G. W. , Sleigh J. W. , Smith P.
Published: January 2019

Most previous studies which have assessed the depth of anaesthesia using the Bispectral Index (BIS) have used multi-agent anaesthetics with relatively slow induction and recovery times. Elevation of electroencephalographic (EEG) Beta/Alpha Ratio has been linked to onset of midazolam amnesia. Propofol anaesthesia for cardioversion in 19 patients enabled us to profile the changes in BIS and Beta/Alpha Ratio during a short, single-agent anaesthetic with a relatively rapid induction and recovery period. BIS values did not alter significantly through onset of amnesia and hypnosis as compared with awake values. Cardioversion occurred over a wide range of BIS values (38 to 94), with recovery at a median BIS value of 79. We observed the BIS to lag about 60s behind the clinical situation (termed BIS60). The BIS60 more closely tracked the clinical level of consciousness, showing statistically significant differences from the uncorrected BIS. (amnesia (median BIS60=82, P=0.02), hypnosis (median BIS60=67, P=0.01), eye opening (median BIS60=90, P=0.001)). An early EEG Beta/Alpha Ratio peak occurred at a mean of 4.6s (SD=16.6) after clinical amnesia onset and a late peak at a mean 58s (SD=144) after eye opening. There was no significant EEG response to cardioversion. We conclude that: (1) in rapidly changing conditions, the value of the BIS most accurately reflects the level of consciousness of the patient about 60s in the past, and (2) the onset and offset of propofol-induced amnesia commonly corresponds to a peak in Beta/Alpha Ratio of the EEG.
Pre-emptive Analgesia with Epidural Morphine or Morphine and Bupivacaine
Authors: Subramaniam B. , Pawar D. K. , Kashyap L.
Published: January 2019

Studies of pre-emptive analgesia in humans have shown conflicting results. The study design, patient population and the duration of assessment of postoperative pain are important in the evaluation of pre-emptive analgesia. We carried out a prospective, randomized, double-blind controlled study in 80 patients of physical status ASA 1–3 undergoing upper abdominal and thoracic surgery. Patients received two epidural injections, one 20 minutes before induction and the other at the end of surgery. Study solution was either morphine (50 μg/kg), with or without 0.1% bupivacaine in 10 ml of normal saline, or normal saline alone. The study groups (Pre M, Pre MB) were given either morphine or morphine-bupivacaine before induction and saline at the end of surgery. The control groups (Post M, Post MB) were given saline before induction and morphine or morphine-bupivacaine at the end of surgery. Postoperative pain was assessed with a Visual Analogue Scale (VAS) during coughing and deep breathing at six-hourly intervals for five days. Epidural morphine was given if the VAS exceeded 4.

Pre MB compared to Post MB had a significantly increased interval between the analgesic top-ups (P<0.01) and decreased total postoperative morphine requirements (P<0.0001) and number of top-ups (P<0.001). Pre M and Post M were comparable. Pre MB compared to Pre M had significantly decreased total postoperative morphine requirements (P<0.0001) and number of top-ups (P<0.0001). Epidural morphine plus bupivacaine is effective as a pre-emptive analgesic. Morphine plus bupivacaine has better efficacy than morphine given alone before the induction of anaesthesia.
Prediction of the Mediastinal Drainage after Coronary Artery Bypass Surgery
Authors: Liu G. , McNicol P. L. , McCall P. R. , Bellomo R. , Connellan# J. , McInnes F. , Przybylowski G. M. , Bowkett J. , Choo F. , Thurlow P. J.
Published: January 2019

Using multiple correlation and linear regression approaches, we investigated the association between the amount of mediastinal drainage for the first 24 postoperative hours and clinical variables as well as multiple haematological tests performed at three time points: before anaesthesia induction, 10 minutes after protamine administration and just after skin closure, on 46 patients undergoing primary coronary artery bypass grafting. Three models from the three times were then developed to predict mediastinal drainage. The number of internal mammary grafts, the total number of grafts and plasma fibrinogen concentration were useful predictors of mediastinal drainage at all three times. The platelet count taken only after skin closure was found to provide additional predictive information. Each regression model explained approximately 60% of the variation in postoperative mediastinal drainage. The information obtained from these predictive models is useful in defining high-risk populations.
Clinical Evaluation of the Non-Invasive Cardiac Output (NICO) Monitor in the Intensive Care Unit
Authors: Van Heerden P. V. , Baker S. , Lim S. I. , Weidman C. , Bulsara M.
Published: January 2019

The Non-invasive Cardiac Output (NICO) monitor (Novametrix Medical Systems Inc., Wallingford, CT, U.S.A.) utilizes a minimally-invasive partial rebreathing method to determine cardiac output by means of a differential form of the Fick equation. We evaluated the NICO monitor by comparing its output to paired measurements obtained by the standard thermodilution (TD) technique in patients who had recently undergone cardiac surgery. Forty-two paired measurements were carried out in 12 patients. The correlation between the two methods was moderate with a correlation coefficient of 0.691. Repeated measures ANOVA showed that TD measures of cardiac output were significantly higher than those obtained by the NICO monitor (P=0.0003). Comparison of the two techniques using the method described by Bland and Altman showed decreased correlation at higher values of cardiac output.

We conclude that the NICO monitor may well have a place in intensive care monitoring, provided patients are not breathing spontaneously and are able to tolerate a 4 mmHg rise in P a co 2. It is less suitable for use in patients with a high cardiac output state.
Effect of Short-Term Ketorolac Infusion on Recovery following Laparoscopic Day Surgery
Authors: Campbell L. , Plummer J. , Owen H. , Czuchwicki A. , Ilsley A.
Published: January 2019

This study tested the hypothesis that, by the addition of parenteral ketorolac to an oral analgesic regimen for one day following laparoscopic surgery, analgesia would be improved and thus the return of normal function hastened. Seventy-two female patients were randomly assigned to receive ketorolac 10.5 mg subcutaneously at the end of surgery followed by a subcutaneous infusion of 1.75 mg/h for 24 to 36 hours, or an equivalent volume of saline. All patients were provided with codeine tablets (30 mg) for analgesia if required. For the first four postoperative days patients recorded details of pain, side-effects and discomfort on performing everyday activities. Patients who received ketorolac received significantly less fentanyl in the Recovery Ward and significantly less codeine prior to discharge than the saline group. They also took significantly fewer codeine tablets over the four-day postoperative period. Pain scores in the ketorolac group were not significantly lower than in the saline group on the first postoperative day (P=0.052) and subsequently remained similar. Levels of discomfort on performing six common activities were similar in the two groups over the four-day postoperative period. We conclude that, despite beneficial effects during the period of ketorolac administration, there was no continuing benefit after this time other than reduced analgesic use, and no improvement in the patients’ ability to perform common activities.
Knowledge of Cardiopulmonary Resuscitation Protocols and Level of Anaesthetic Training
Authors: Cowie D. A. , Story D. A.
Published: January 2019

Inadequate recall of resuscitation protocols has contributed to poor performance of resuscitation in simulation studies. We asked, does the level of anaesthesia training affect knowledge of cardiopulmonary resuscitation protocols? We used a questionnaire that covered the areas of basic life support, advanced adult life support and paediatric life support. The proportions of correct answers were hospital medical officers 50%, junior registrars 62%, senior registrars 84% and consultants 42%. The consultant group performed worse than all other groups for the basic life support and advanced life support questions. We suggest yearly resuscitation training for all anaesthetists and anaesthesia trainees.
A Randomized Comparison of Low-Dose Ketamine and Lignocaine Infiltration with Ketamine-Diazepam Anaesthesia for Post Partum Tubal Ligation in Vanuatu
Authors: Grace R. F. , Lesteour T. , Sala T. , Stewart J.
Published: January 2019

Ketamine remains one of the most commonly used anaesthetic agents around the world. Despite it being the anaesthetic agent of choice in many developing nations, there is a paucity of literature describing ketamine in the developing world. In what we believe is the first randomized controlled trial to be performed in Vanuatu (formerly the New Hebrides) we compared the use of ketamine 0.9 mg/kg and diazepam 0.07 mg/kg with ketamine 0.3 mg/kg and 2% lignocaine infiltration in 50 Melanesian women undergoing post partum tubal ligation. All women received 0.5 mg/kg intramuscular pethidine.

Visual analog pain scores and verbal numeric satisfaction scores were similar between the groups. However the time to obeyed command was significantly faster in the 0.3 mg/kg ketamine group (7.0±4.9 vs 13.0±9.2 min). The incidence of dreaming was similar and the content rated as pleasant by both groups. In institutions where post-anaesthesia care resources are limited, 0.3 mg/kg ketamine with local anaesthesia provides for earlier self-care of patients after tubal ligation, without compromise of analgesia, emergence or satisfaction. The implications of these findings extend to other procedures that require short general anaesthesia, which can be adequately performed with low-dose ketamine and local anaesthesia. The latter technique allows more rapid awakening.
Anaesthesia and Myotonia—An Australian Experience
Authors: Imison A. R.
Published: January 2019

The purpose of this audit was to retrospectively examine the anaesthetic technique and perioperative complications among adult patients with confirmed myotonic dystrophy who presented for surgery at Royal Perth Hospital. A total of 18 general anaesthetics, two spinal anaesthetics, one conscious sedation and six eye blocks were performed. No deaths and no myotonic episodes were described despite the use of a variety of techniques, including the administration of succinylcholine to three patients. The only patient to experience postoperative complications was severely unwell preoperatively and underwent upper abdominal surgery. The audit revealed an overall complication rate of 5.5% of general anaesthetics or 3.8% of all anaesthetics in this patient population.
Bilateral Frontal Haemorrhages Associated with Continuous Spinal Analgesia
Authors: Crofts T. R. , Monagle J. , Buist M. , Burnes J.
Published: January 2019

We report a case of intracerebral haemorrhages associated with continuous spinal analgesia. Continuous spinal analgesia is frequently employed for postoperative analgesia in high-risk patients in our institution. The analgesia is administered via a 20 gauge catheter passed through an 18 gauge Tuohy needle (Portex). A 71-year-old man with severe respiratory impairment had an intrathecal catheter placed for postoperative analgesia. He had a difficult postoperative course, including wound dehiscence, and died from respiratory failure some five weeks postoperatively. On day nine postoperatively he had two tonic-clonic seizures and was subsequently found to have developed bilateral frontal intracerebral haemorrhages. There was no previous history of seizures. Although several confounding variables exist, the most likely explanation for the intracerebral event appears to be an association with the dural puncture and intrathecal catheter. Possible mechanisms and risk factors are discussed.
Acute Haemorrhagic Leucoencephalitis Complicating Sepsis
Authors: Tanser S. J. , Walker M. B. , Hilton D. A.
Published: January 2019

A case of acute haemorrhagic leucoencephalitis presenting as fatal septic encephalopathy is reported. The clinical features of this condition are reviewed and the potential for earlier diagnosis is considered.
Anterior Spinal Artery Syndrome following Total Hip Arthroplasty under Epidural Anaesthesia
Authors: Hong D. K. , Lawrence H. M.
Published: January 2019

We present a case of anterior spinal artery syndrome in a 57-year-old man having a total hip arthroplasty under epidural anaesthesia. Epidural insertion and surgery were uneventful. Postoperatively bilateral lower limb motor weakness was attributed to the initial dose of local anaesthetic. There was no change in neurological status 24 hours later. Magnetic resonance imaging demonstrated spinal cord infarction. The diagnosis of anterior spinal artery syndrome was made based on the patient's neurological condition and MRI findings.
Anaesthetic Management of a Caesarean Section in a Patient with Marfan's Syndrome and Aortic Dissection
Authors: Brar H. B. K.
Published: January 2019

This report describes a case of a Stanford Type B aortic dissection (originating distal to the left subclavian artery and extending to the aortic bifurcation and proximal left iliac artery) in a 31-year-old primigravid woman who was at 39 weeks gestation and had Marfan's syndrome. The dissection was managed conservatively. Caesarean section was performed under epidural anaesthesia with aggressive control of hypertension. Postoperatively, there was no extension of the dissection and no aneurysm formation. She was discharged from hospital two weeks after delivery and remained asymptomatic at six months. There are no plans for surgical intervention.
Tracheal Intubation without Muscle Relaxant—A Technique Using Sevoflurane Vital Capacity Induction and Alfentanil
Authors: Sivalingam P. , Kandasamy R. , Dhakshinamoorthi P. , Madhavan G.
Published: January 2019

This randomized controlled study examined intubating conditions and haemodynamic changes following sevoflurane nitrous oxide induction in four groups: three different doses of alfentanil compared with low-dose alfentanil and suxamethonium. All patients received atropine 0.3 mg IV before induction of anaesthesia with vital capacity breaths of sevoflurane 8% (more than 7% in the inspiratory gas) in 60% nitrous oxide and oxygen. Patients were allocated randomly to four groups of intravenous supplements: group SA20, alfentanil 20 μg.kg -1; group SA25, alfentanil 25 μg.kg -1; group SA30, alfentanil 30 μg.kg -1; group SSA, alfentanil 10 μg.kg -1 and suxamethonium 1 mg.kg -1. Orotracheal intubation and assessment of intubating conditions was performed by one of the investigators who was blinded to the subject's group. Intubating conditions were satisfactory or excellent in 83%, 80%, 92% and 96% of patients in groups SA20, SA25, SA30 and SSA respectively. These differences were not statistically significant. The increase in heart rate associated with laryngoscopy and tracheal intubation was effectively attenuated in all groups. Mean arterial pressure decreased significantly and similarly after induction in all groups. Two minutes after intubation the mean arterial pressure was increased significantly (P<0.05) compared to the post-induction value in group SSA. The intubating conditions obtained with sevoflurane plus alfentanil 30 μg.kg -1 were comparable to those provided by the sevoflurane, suxamethonium and alfentanil 10 μg.kg -1 combination.
Latex Hypersensitivity in Spinal Cord Injured Adult Patients
Authors: Mertes P. M. , Mouton C. , Frémont S. , Brugerolle B. , Moneret-Vautrin D. A. , Lavaud F. , Laxenaire M. C.
Published: January 2019

Latex hypersensitivity is a major cause of anaphylaxis during anaesthesia. Patients with spina bifida, health care or rubber industry workers have been considered at risk for latex sensitization. By analogy, the existence of other at-risk subsets of patients with latex exposure due to frequent surgical procedures has been suggested.

The aim of this study was to evaluate the prevalence of latex sensitization in a cohort of adult patients with spinal cord injury and repeated latex exposure.

Forty-two adult patients with spinal cord injury were studied and retrospectively compared to a group of 30 children with spina bifida evaluated using a similar protocol.

Patients were administered a questionnaire concerning history of latex hypersensitivity, atopy, and surgical procedures. Latex sensitivity was investigated by skin prick-tests and latex-specific IgE assay. The search for atopy was based on in vivo and in vitro tests against a panel of environmental allergens.

No chronic spinal cord injured patient had a history of latex allergy. When compared with spina bifida, the number of surgical procedures was not statistically different. Although not significantly different, the prevalence of atopy was higher in spina bifida patients. The high level of latex sensitization in spina bifida patients contrasted sharply with the absence of sensitization observed on both skin and in vitro tests in patients with spinal cord injury (P<0.0001).

This study confirms that adult patients with chronic neurologic defects resulting from spinal cord injury exhibit a low risk of latex sensitization. These results suggest that considering adult patients with repeated surgical procedures as a group at risk for latex sensitization because of a high degree of latex exposure should be re-examined.
Intrahospital Transport of Critically Ill Patients: Complications and Difficulties
Authors: Lovell M. A. , Mudaliar M. Y. , Klineberg P. L.
Published: January 2019

An audit of 97 intrahospital transports of critically ill patients was undertaken within Westmead Hospital. The aims of this audit were to assess all factors that may lead to problems during intrahospital transports. At the completion of a transport medical staff were asked to provide information about their patient and their treatment, as well as any difficulties they may have encountered. Overall, 62% of transports reported some difficulty or complication. Of these, 31% were patient-related and 45% were related to equipment or the transport environment. (15% encountered problems in both areas). Many of the difficulties were preventable with adequate pre-transport communication and planning. Other problems were directly related to the increased severity of illness in these patients.
Anaesthetic Considerations for Patients Undergoing Hypothermic Cardiopulmonary Bypass for Complex Neurovascular Lesions: Case Presentation and Review
Authors: Burgess N. , Isert P.
Published: January 2019

The anaesthetic management of a 38-year-old woman having excision of a meningioma involving the superior sagittal sinus is described. The procedure was performed using low flow moderate hypothermic cardiopulmonary bypass with central cannulation. Relevant literature is reviewed.
General Anaesthesia in a Patient with Undiagnosed “Saber-Sheath” Trachea
Authors: Garstang J. S. , Bailey D. M.
Published: January 2019

Saber-sheath trachea describes an abnormality in the shape of the trachea caused by underlying disease processes. We present a case of tracheal stenosis in a patient with undiagnosed saber-sheath trachea, in which there was unexpected difficulty in ventilating the lungs despite a good view at laryngoscopy and visually confirmed tracheal intubation.
Concealed Post-Tonsillectomy Haemorrhage Associated with the Use of the Antiemetic Tropisetron
Authors: Herreen P. G. , Wiese M. C. R.
Published: January 2019

A two-year-old child experienced concealed haemorrhage after adenotonsillectomy. In our patient, the absence of vomited or significant gastric blood and the presence of melaena stools may partly be attributed to prophylactic antiemetic treatment with tropisetron.

This group of patients has a high incidence of postoperative nausea and vomiting, and antiemetic treatment is important and valuable. Rather than advocating the withholding of prophylactic antiemetic treatment, we suggest that whatever medication and techniques are used, good clinical care is dependent on careful postoperative observation and assessment for an appropriate period of time.
Reduced Red Cell 2,3-Diphosphoglycerate Concentrations in Critical Illness without Decreased in Vivo P50
Authors: Morgan T. J. , Koch D. , Morris D. , Clague A. , Purdie D. M.
Published: January 2019

We investigated whether red cell 2,3-diphosphoglycerate (2,3-DPG) concentrations are reduced in critical illness, whether acidaemia, hypophosphataemia or anaemia influence 2,3-DPG, and whether there is any net effect on in vivo P50.

Twenty healthy, non-smoking, male volunteers were compared with 20 male intensive care patients with APACHE 2 scores >20 on the preceding day. Those transfused in this time were excluded. Venous red cell 2,3-DPG concentrations were measured in both groups. In the patient group, routine multichannel biochemical profile and arterial blood gas analysis were also performed and in vivo P50 calculated.

The mean 2,3-DPG concentration was significantly lower in the patient group than in the controls (4.2±1.3 mmol/l vs 4.9±0.5 mmol/l, P=0.016). The patients were well oxygenated (lowest arterial PO2=75 mm Hg) and showed a tendency to acidaemia (median pH 7.37, range 7.06 to 7.48) and anaemia (median haemoglobin concentration 113 g/l, range 89 to 154 g/l). By linear regression of patient data, pH had a significant effect on 2,3-DPG concentrations (r=0.6, P=0.011). Haemoglobin and phosphate concentrations did not, but there were few abnormal phosphate values. There was no correlation between 2,3-DPG concentrations and in vivo P50 (r2 ≤0.08).

We conclude that 2,3-DPG concentrations were reduced in a broad group of critically ill patients. Although this would normally reduce the P50, the reduction was primarily linked with acidaemia, which increases the P50. Overall, there was no net effect on the P50 and thus no affinity-related decrease in tissue oxygenation.
Effects of Nimodipine on Tissue Lactate and Malondialdehyde Levels in Experimental Head Trauma
Authors: Ak A. , Üstün M. E. , Gün C. Ö. Ö , Duman A. , Bor M. A.
Published: January 2019

We studied the effects of nimodipine on brain tissue lactate and malondialdehyde (MDA) levels one hour after experimental head trauma in 25 New Zealand rabbits. Group 1(n=5) was the sham operated group. Group 2 (n=10) received head trauma without treatment and in group 3 (n=10) nimodipine was administered for 30 minutes intravenously (2 μg/kg/min) immediately after head trauma. In groups 2 and 3, tissue samples from the non-traumatized side was named as “a” and traumatized side as “b”. The lactate and malondialdehyde contents were significantly higher in groups 2a, 2b, 3a and 3b when compared with to group 1 (P<0.05). The differences between non-treated groups (2a, 2b) and nimodipine treated groups (3a, 3b) were not significant (P>0.05). The differences between the traumatized sides (2b, 3b) and non-traumatized sides (2a, 3a) were significant (P<0.05). These results demonstrated that nimodipine is ineffective in suppressing the increase of tissue lactate and malondialdehyde levels in the early period of experimental head trauma.
Haemodilution-Induced Enhancement of Coagulation is Attenuated in Vitro by Restoring Antithrombin III to Pre-Dilution Concentrations
Authors: Ruttmann T. G. , James M. F. M. , Lombard E. H.
Published: January 2019

Moderate haemodilution enhances coagulability in vitro and in vivo as measured by thrombelastography (TEG). The mechanism has never been established. We have conducted an in vitro study to determine whether the effect can be moderated or prevented when the reduction in antithrombin III caused by dilution is prevented by supplementation.

Blood from 20 volunteers was divided into four samples. One sample was not diluted and served as control (C). Another was diluted (by 20%) with saline (S). The third was diluted by 20% with saline plus two units of antithrombin (AT III) (SA). The fourth remained undiluted, with two units of added AT III (CA). Coagulation was measured in all four samples using the TEG. In a separate laboratory study, the levels of AT III were measured in control samples and compared with levels after 20% dilution, and 20% dilution with two units of AT III added to the diluent.

Enhanced coagulation was demonstrated in saline-diluted samples (S) by shortening of r- and k-times, and increased alpha angle. In the SA samples, r-time shortening was prevented; k-time shortening and alpha-angle increase persisted, but to a reduced degree (difference from saline-only dilution P<0.051). There were no differences between samples C and CA. A predictable drop of AT III (24.2%) occurred with saline dilution, while AT III levels in the AT III/Saline group were similar to the undiluted control.

Haemodilution-induced coagulation enhancement is attenuated, but not prevented, if AT III levels are maintained in the normal range. This is in keeping with the established concept of an antithrombin threshold preventing positive coagulation feedback into the intrinsic pathway.
Comparison of Isoprenaline with Adrenaline as Components of Epidural Test Dose Solutions for Halothane Anaesthetized Children
Authors: Tyagi A. , Sethi A. K. , Chatterji C.
Published: January 2019

In this randomized controlled trial we studied the haemodynamic effects of intravenous injection of lignocaine 1 mg/kg with either no additive, isoprenaline 0.05 μg or 0.075 μg/kg, or adrenaline 0.5 μg/kg in children anaesthetized with halothane. An increase of 10 bpm in heart rate or 20% rise in blood pressure was taken as a positive test response. Adrenaline was confirmed to be an unreliable marker with a positive test in only 67% of cases. For both doses of isoprenaline, the heart rate changes produced a positive test in 100% of cases. There was no statistically significant difference between the two doses of isoprenaline in regard to mean maximum increase in heart rate, mean time of beginning, ending or duration of positive test response and mean time to reach peak heart rate. The positive test response began between 10 and 50 seconds and lasted for an average of 69±54 seconds with the lower dose of isoprenaline 0.05 μg/kg. No advantage could be seen with the higher dose of isoprenaline. Change in blood pressure was not a useful criterion to detect intravascular injection. Recommendations for the use of isoprenaline as a marker of intravascular injection during regional blockade must be deferred until the safety of this agent's effect on neurological tissue is confirmed.
Internal Jugular Vein Patency following Carotid Endarterectomy
Authors: Mann T. , Johnson F. , Cokis C.
Published: January 2019

We performed ultrasound examinations on forty-five patients with a history of carotid endarterectomy to assess the patency and position of the internal jugular vein on the side of the endarterectomy. The study was performed in a tertiary referral centre. In the 55 internal jugular veins examined (ten bilateral procedures), the veins were patent and in a normal relationship to the carotid artery. We concluded that previous carotid surgery should not be a contraindication to cannulation of the internal jugular vein.
An Evaluation of Non-Invasive Blood Pressure (NIBP) Monitoring on the Wrist: Comparison with Upper Arm NIBP Measurement
Authors: Emerick D. R.
Published: January 2019

The arm is the traditional site for application of an oscillometric non-invasive blood pressure (NIBP) cuff. This study, which compares upper arm NIBP to wrist NIBP, involved 510 same arm sequential paired blood pressure (BP) measurements in 85 volunteers.

Wrist NIBP consistently overestimated mean arterial, systolic and diastolic pressure by approximately 10 mmHg. Ninety per cent of the mean arterial pressure differences at the wrist were within a range of ±9 mmHg around a mean difference of 10.6 mmHg. The systolic pressure difference was 11.2 mmHg with 90% of differences between ±12 mmHg. The diastolic pressure difference was 10.2 mmHg with 90% of differences between ±9 mmHg.

With the device used and within the normal blood pressure range, compensation can be performed by subtracting 10 mmHg from the measured values or simply by elevating the wist about 15 cm and taking the BP at face value. Wrist NIBP may be a viable clinical alternative in situations where difficulty occurs with upper arm NIBP measurement.
Diclofenac or Paracetamol for Analgesia in Paediatric Myringotomy Outpatients
Authors: Tay C. L. M. , Tan S.
Published: January 2019

This prospective, randomized, double-blind study compared the analgesic efficacy of oral diclofenac resinate 0.5 mg.kg -1 with paracetamol 15 mg.kg -1 for control of postoperative pain in paediatric patients for outpatient bilateral myringotomy and tube insertion. Paracetamol, the most commonly used oral analgesic for paediatric patients, was compared with a new palatable syrup formulation of diclofenac.

Sixty-three ASA 1 or ASA 2 children aged one year and above were randomly assigned to receive diclofenac (Group A) or paracetamol (Group B). The study drug was given 30 to 60 minutes before induction of anaesthesia. Anaesthesia was induced with either inhalational sevoflurane or intravenous thiopentone. All subjects received intravenous fentanyl 1 μg.kg -1 intraoperatively. Postoperative pain was assessed by a blinded observer using the CHEOPS score on eye-opening, and then at 10, 30 and 60 minutes. Children with a CHEOPS score >7 received further fentanyl 1 μg.kg -1. The number of cases requiring this “rescue” analgesia was recorded.

Both groups were comparable in demographics, induction technique, duration of anaesthesia and time between premedication and induction of anaesthesia. Overall, CHEOPS scores were low for both groups at all times and did not differ between the groups at any time. Twenty per cent of the diclofenac group and 27% of the paracetamol group required rescue analgesia (not statistically significant). The efficacy of diclofenac 0.5 mg.kg –1 and paracetamol 15 mg.kg –1 as oral analgesic premedication for BMT was comparable in children receiving an anaesthetic which included intraoperative administration of fentanyl 1 μg.kg –1.
Acute Lithium Intoxication
Authors: Nagappan R. , Parkin W. G. , Holdsworth S. R.
Published: January 2019

We present a case of acute lithium intoxication in a 51-year-old woman on chronic lithium therapy. Her serum lithium level was 10.6 mmol/l 13 hours after ingestion and 5.8 mmol/l at 24 hours. Dialysis therapy was not employed and she recovered well after fluid resuscitation. Serum lithium levels in chronic intoxication are more indicative of intracellular lithium concentration and therefore of clinical toxicity, as opposed to serum lithium levels in acute intoxication. Clinical features of toxicity are more important than a spot lithium level. A combination of clinical toxicity, the duration of exposure and a serial profile of serum lithium levels should guide dialytic therapy for removal of lithium.
Combined Spinal Epidural Anaesthesia for Vesico-vaginal Fistula Repair in an Achondroplastic Dwarf
Authors: Trikha A. , Goyal K. , Sadera G. S. , Singh M.
Published: January 2019

A 33-year-old achondroplastic female was scheduled to undergo vesico-vaginal fistula repair by the abdominoperineal route. Preoperative examination suggested a difficult airway so a combined spinal epidural technique was used. Subarachnoid block (sensory loss to T6) was established using 0.5% hyperbaric bupivacaine 1 ml. Anaesthesia was prolonged with incremental doses of epidural bupivacaine 0.5% (total 10 ml) and postoperative analgesia was provided with epidural morphine boluses.
Propofol and Midazolam versus Propofol Alone for Sedation following Coronary Artery Bypass Grafting: A Randomized, Placebo-controlled Trial
Authors: Walder B. , Borgeat A. , Suter P. M. , Romand J. A.
Published: January 2019

The aim was to compare the efficacy and side-effects of propofol combined with a constant, low dose of midazolam versus propofol alone for sedation. In a prospective, randomized and double-blinded study, 60 male patients scheduled for elective coronary bypass grafting were enrolled. Postoperatively, patients were stratified to receive either a continuous intravenous infusion of midazolam 1 mg/h or placebo. Target Ramsay sedation score was 3 to 5 corresponding to conscious sedation. An intention-to-treat design for propofol was performed to reach target sedation. Efficacy of sedation was statistically significantly higher in the group midazolam+intention-to-treat with propofol compared with the group placebo+intention-to-treat with propofol (91% vs 79%; P=0.0005). Nine of 27 patients in the midazolam group (33.4%) and nine of 26 patients in the placebo group (34.6%) needed no supplementary propofol. Weaning time from mechanical ventilation was longer in the midazolam group whether or not they required supplemental propofol when compared with placebo group (all: 432±218 min vs 319±223 min; P=0.04; supplementary propofol: 424±234 min vs 265±175 min; P=0.03). The cumulative number of patients remaining intubated was significantly higher in the group midazolam+propofol compared with the group placebo+propofol (P=0.03). In conclusion, target sedation is reached slightly more often by the co-administration of propofol and a low dose of midazolam, but weaning time from mechanical ventilation is prolonged by the co-administration of propofol and a low dose of midazolam.
Inhibition of Bacterial Growth by Lignocaine in Propofol Emulsion
Authors: Ozer Z. , Ozturk C. , Altunkan A. A. , Cinel I. , Oral U.
Published: January 2019

Contamination of propofol, in an emulsion formulation, has been associated with infective complications. Local anaesthetics, some of which are known to have antibacterial properties, are frequently added to the solution to reduce pain on injection.

We examined the growth rates of E. coli, S. aureus, S. epidermidis and P. aeruginosa in propofol with and without lignocaine 0.1%–2% after incubation for 2, 5 and 24 hours at 37°C. Growth of microorganisms in each solution was compared by counting the number of colony forming units (CFU).

Propofol supported the growth of all microorganisms. An increase in the number of CFUs was observed in all drug combinations 2, 5 and 24 hours after inoculation except for S.aureus (P<0.05). No difference was found in CFU numbers between 2 and 5 hours for this microorganism. With E.coli, a significant decline in colony counts was observed in mixtures of 1% and 2% lignocaine (P<0.05). With the other microorganisms only 2% lignocaine showed a significant reduction in the number of CFUs (P<0.05).

We conclude that lignocaine in recommended clinical doses (0.05%–0.1%) did not exhibit adequate antibacterial activity to prevent infective complications.
Cerebral Protection with Thiopentone during Combined Carotid Endarterectomy and Clipping of Intracranial Aneurysm
Authors: Mcconkey P. P. , Kien N. D.
Published: January 2019

We report a case of carotid endarterectomy and clipping of an ipsilateral internal carotid artery aneurysm in a patient with complete contralateral carotid stenosis. The patient developed an ischaemic electroencephalographic (EEG) tracing on temporary carotid clamping and bypass shunt was contraindicated. We used thiopentone titrated to EEG burst suppression for pharmacological cerebral protection during the subsequent prolonged carotid clamp necessary for carotid endarterectomy. We review the use of thiopentone for this purpose, in particular the evidence for efficacy, mechanism of action and optimal dosage and timing of administration.
Prone Position as a Life-saving Measure for Acute Pulmonary Haemorrhage in a Young Adult with Cystic Fibrosis
Authors: Savage R.
Published: January 2019

Fatal pulmonary haemorrhage is a rare complication of cystic fibrosis. A case of unexpected life-threatening pulmonary haemorrhage is presented, and the successful management of this problem including immediate prone ventilation. Different anaesthetic techniques, avoiding endotracheal intubation and positive pressure ventilation, which may avoid similar complications, are described.
Acute Autoimmune Cardiomyopathy in Primary Antiphospholipid Antibody Syndrome
Authors: Nagappan R. , Lodge R. S.
Published: January 2019

We present a case of acute pulmonary oedema as the first presentation of autoimmune cardiomyopathy in primary antiphospholipid antibody syndrome in a patient who had no previous cardiac history. Five days of methylprednisolone at 500 mg/day followed by 100 mg/day for 10 days and then a weaning course of oral prednisone resulted in effective resolution of the acute diffuse cardiomyopathy. Her cardiac status became clinically and echocardiographically normal. We illustrate the effectiveness of immunosuppressive therapy as an adjunct to standard anti-failure measures in such presentations and we outline the association between antiphospholipid antibodies and cardiac dysfunction.