bluuebunny/crossref_metadata_2025 huggingface dataset:
Repeated Intrathecal Administration of Ropivacaine Causes Neurotoxicity in Rats
Authors: Zhong Z. , Qulian G. , Yuan Z. , Wangyuan Z. , Zhihua S.
Published: January 2019

Previous studies suggest that ropivacaine causes the least neurotoxicity among local anaesthetics. Most data derive from a single injection of ropivacaine into the subarachnoid space. The histological changes and behavioural effects of repeated intrathecal administration have yet to be studied. We examined the possible neurotoxicity of multiple doses of intrathecal ropivacaine in rats.

Rats received 0.12 ml/kg body weight ropivacaine in normal saline at concentrations of 0.25%, 0.5%, 0.75% and 1.0% at 90-minute intervals via an implanted intrathecal catheter (ID 0.12 mm, OD 0.35 mm) for 48 hours. At L3, the spinal cord and posterior roots were examined by light and electron microscopy. We performed in situ TUNEL assay to evaluate apoptosis in the spinal cord. Sensory threshold to noxious stimulation along with behavioural change were also studied.

Both 0.75% and 1.0% ropivacaine induced neuronal injury characterised by infiltration of inflammatory cells, vacuolation of myelin sheaths and axons, abnormal morphology of neurons and apoptosis in the spinal cord, mainly in posterior roots and the adjacent posterior white matter. Compared to controls, the percentage of maximum possible effect did not show any significant differences between the rats treated with variable concentrations of ropivacaine or tested with either heat or mechanical stimulation. As expected, the recovery time to normal ambulation was prolonged as the ropivacaine concentration was increased.

Ropivacaine can induce neurotoxicity and trigger apoptosis in a dose-dependent manner after repeated intrathecal administration. Although the clinical safety profile of ropivacaine appears favourable compared with other local anaesthetics, it is possible our findings have clinical significance.
The Effects of Prostaglandin E1 on Interleukin-6, Pulmonary Function and Postoperative Recovery in Oesophageetomised Patients
Authors: Farrokhnia F. , Makarem J. , Khan Z. H. , Mohagheghi M. , Maghsoudlou M. , Abdollahi A.
Published: January 2019

The inflammatory reactions and tissue response after oesophagectomy are leading causes of postoperative morbidity and mortality. We evaluated the effects of intraoperative infusion of prostaglandin E1 (PGE1) on interleukin-6 (IL-6) levels, (A-a) DO2, pulmonary function and complications. This randomised double-blind clinical trial study was performed on patients undergoing transthoracic oesophagectomy due to cancer. Thirty patients were randomly allocated to two groups: the PGE1 group (infusion of PGE1, 20 ng.kg−1.min−1) and a placebo group (infusion of normal saline 0.9%). The infusion was started before induction of anaesthesia and continued until the end of the operation. The groups were comparable in basic characteristics and preoperative pulmonary function. Patients in the PGE1 group were discharged significantly earlier from the intensive care unit (72±9 vs 83±17 hours) and hospital (13±4 vs 18±8 days) (P=0.04 and 0.03, respectively). The (A-a) DO2 was significantly less in the PGE1 group at 12 and 24 hours after the operation (P=0.001, P=0.003, respectively). Postoperatively, IL-6 levels were significantly higher in the placebo group than in the PGE1 group. There were no differences in the forced expiratory volume in the first second or forced vital capacity. The findings indicate that infusion of PGE1 attenuates the increase in serum levels of IL-6 in patients undergoing esophagectomy and improves the (A-a) DO2. Stays in the intensive care unit and hospital were shorter in the PGE1 group. However, there were no differences in pulmonary complications.
Brain Death in a Septic Patient: Possible Relationship with Posterior Reversible Encephalopathy Syndrome?
Authors: Huberlant V. , Cosnard G. , Hantson P. E.
Published: January 2019

A 41-year-old man with a previous kidney transplant was referred for arterial hypertension and acute renal failure. Initial neurological examination was normal. Laboratory data showed a high serum cyclosporine A concentration. A few hours later, he developed generalised tonic-clonic seizures. The brain computed tomogram was not remarkable, but Glasgow Coma Scale score remained at 8. Mechanical ventilation was required for rapidly progressive hypoxaemia related to Staphylococcus aureus pneumonia and septicaemia. Noradrenaline infusion was needed for only nine hours, with no major drop in mean arterial blood pressure. On day three his Glasgow Coma Scale score was 3/15, with fixed dilated pupils. The brain computed tomogram revealed bilateral hypodense lesions in the posterior areas together with cerebral oedema and the patient was subsequently declared brain dead. We discuss the possibility of a posterior reversible encephalopathy syndrome, likely triggered by a gram-positive septicaemia in addition to other risk factors.
Dr GD Monteith: An Unobtrusive Wellington Surgeon who became Coroner, Provincial Surgeon and Hospital Superintendent
Authors: Newson A. J.
Published: January 2019

The first general surgical operation performed on an etherised patient in New Zealand took place early on the afternoon of Monday, 27 September 1847, at the recently opened Wellington Colonial Hospital1. The surgeon Dr JP Fitzgerald, M.D. was assisted by Dr GD Monteith and the ether was administered by JH Marriott Esq. Whereas the biographies of Dr Fitzgerald and James Marriott have been well documented nationally2, little has been recorded concerning Dr Monteith. The following article has been compiled in an attempt to prevent the life and contributions of Dr Monteith from slipping into oblivion.
William TG Morton's Early Ether Inhalers: A Tale of three Inhalers and their Inscriptions
Authors: Haridas R. P.
Published: January 2019

Three ether inhalers with inscriptions stating that they had been used in early ether anaesthesia were found. All three inhalers were initially linked to WTG Morton. Two of the inhalers were probably among several types of inhalers used by Morton. The third inhaler was found to have been incorrectly attributed to Morton. It was first used by John Foster Brewster Flagg, a dentist in Philadelphia.
Effects of Open Lung Approach Policy on Mechanical Ventilation Duration in Postoperative Patients with Chronic Thromboembolism with Pulmonary Hypertension: A Case-Matched Study
Authors: Imanaka H. , Takeuchi M. , Tachibana K. , Konishi K. , Nishimura M.
Published: January 2019

Patients with chronic thromboembolism with pulmonary hypertension (CTEPH) often develop severe hypoxaemia after pulmonary thromboendarterectomy. There is reluctance to apply high positive end-expiratory pressure (PEEP) to those patients, whereas high PEEP is important for acute hypoxaemic respiratory failure due to alveolar collapse. Open lung approach (OLA) policy, a combination of recruitment manoeuvre and PEEP titration, may improve oxygenation and lung mechanics in acute hypoxaemic respiratory failure, but the effect of OLA on the outcome is unknown. We designed a case-matched, retrospective study to investigate whether OLA policy improved the outcome of postoperative patients with CTEPH.

Among 113 postoperative patients with CTEPH, 40 were chosen before and after the introduction of an OLA policy to create 1:1 ratio of case-match according to gender, age and preoperative total pulmonary resistance index (conventional treatment group vs OLA group). In the OLA group, recruitment manoeuvre was applied and then PEEP was titrated to maintain oxygenation every 12 hours. Gas exchange and duration of mechanical ventilation were compared between the groups.

The OLA group showed higher PaO2/FiO2 ratio at 12 hours after the surgery than the conventional group (P=0.0021). In the OLA group, duration of mechanical ventilation was shorter than the conventional treatment group (median, 23.5 hours vs 43 hours, P=0.0064). The OLA group showed lower cardiac index, higher pulmonary artery pressure and higher total pulmonary resistance index after the surgery than the conventional group.

The introduction of the OLA policy may have shortened mechanical ventilation duration despite what appeared to be less favorable early postoperative hemodynamics in patients after the surgery for CTEPH.
A Retrospective Audit of three Different Regional Anaesthetic Techniques for Circumcision in Children
Authors: Sandeman D. J. , Reiner D. , Dilley A. V. , Bennett M. H. , Kelly K. J.
Published: January 2019

Postoperative analgesia for male circumcision surgery has been traditionally provided by a landmark-based dorsal penile nerve block (DPNB-LM) or by caudal epidural analgesia (CEA). In this study we report on a retrospective analysis of the effectiveness and safety of CEA, DPNB-LM and ultrasound-guided dorsal penile nerve block (DPNB-US) in our institution over a six-year period. Information was gathered from each patient's medical record. A total of 216 circumcisions were performed on patients aged from five months to 15 years. One hundred and fifteen patients received CEA, 46 DPNB-LM and 55 DPNB-US. Patients in the DPNB-LM group required rescue morphine administration in the recovery unit more frequently (30.4%) than either the DPNB-US (3.5%) or CEA groups (3.6%). Similarly, the DPNB-LM group required a larger total dose of morphine, and had longer recovery ward stays than CEA or DPNB-US groups. Time to first analgesia was greatest for the CEA group while there was no significant difference between time to first analgesia for DPNB-LM and DPNB-US. Sixty-three percent of patients in the DPNB-LM group, 1.7% of CEA and 5.5% of the DPNB-US required intraoperative opiates (P <0.0001). There was no difference in time to hospital discharge.
Caudal Epidural Block in Children: Comparison of Needle Insertion Parallel with Caudal Canal versus Conventional Two-Step Technique
Authors: Shin K.-M. , Park J.-H. , Kil H.-K. , Kang S.-S. , Kim I.-S. , Hong S.-J. , Choi J.-K.
Published: January 2019

This study compared the technique of inserting the needle for caudal epidural blockade in a single pass parallel to the caudal canal versus the conventional technique of approaching the caudal canal with the needle at a steeper angle. Seventy-five patients, aged 0 to 72 months, scheduled for urological surgery were prospectively enrolled in this study. Patients were randomly divided into two groups: a conventional method group (caudal block performed with conventional needle insertion, n=40) and a new method group (needle inserted into the skin at an angle of 20° and into the caudal space without redirection, n=35).

Two anaesthetists (A, B) performed the caudal blocks. For anaesthetist A, the mean time required (standard deviation) to perform needle insertion in the conventional method group was 2.2 (0.8) minutes and in the new method group 1.1 (0.7) minutes (P=0.03). For anaesthetist B the mean time (standard deviation) to perform needle insertion in the conventional method group was 2.1 (1.1) minutes and in the new method group 1.3 (0.8) minutes (P=0.04).

Successful block was considered as first pass placement of the needle in the caudal canal confirmed (after placement) by ultrasound imaging, and the absence of a bloody tap. Subcutaneous placement of the needle after the first attempt occurred in two cases in the conventional method group and three cases in the new method group. Bloody tap occurred in four cases, all in the conventional method group and none in the new method group. When required, the second pass was successful in all cases.
Effects of Clonidine on Recovery after Sevoflurane Anaesthesia in Children Undergoing Cataract Surgery
Authors: Ghai B. , Ram J. , Chauhan S. , Wig J.
Published: January 2019

This trial assessed the effects of two doses of clonidine compared with placebo on the quality and speed of recovery in children premedicated with oral midazolam and anaesthetised with sevoflurane for cataract surgery.

One hundred and twenty American Society of Anesthesiologists physical status I to II children (aged one to six years), premedicated with oral midazolam 0.5 mg/kg and undergoing elective unilateral cataract surgery with sevoflurane anaesthesia were studied. Children were randomised to intravenous clonidine 1 μg/kg (group C1, n=39), 2 μg/kg (group C2, n=41) or normal saline (group NS, n=40). Clinically successful sub-Tenon local anaesthesia block was required for a patient to be included in the analysis.

The primary outcome was the incidence of postoperative agitation. Postoperative agitation was defined as a Pain Discomfort Score of ≥3 using items 3 to 5 only, which was assessed 15 minutely until discharge. Agitation was observed in 11/40 (27.5%) children in the NS group compared to 2/39 (5.1%) in group C1 and none in group C2 (P <0.001). Rescue medication to treat severe agitation was required in 5/40 (12.5%) in the NS group, 1/39 (2.6%) in group C1 and none in group C2 (P=0.025). Time to meet discharge criteria was significantly shorter in group C1 compared to the other two groups (48.4±14.0 minutes compared to C2 79.5±12.8 minutes and NS 73.1±20.4 minutes, P <0.001). There were no significant effects on blood pressure and heart rate.

Intravenous clonidine 1 μg/kg is effective for reducing agitation after sevoflurane anaesthesia and midazolam premedication in children undergoing cataract surgery. Intravenous clonidine 2 μg/kg was also effective and for a longer period, but was associated with a longer time to discharge.
The Financial and Environmental Costs of Reusable and Single-Use Plastic Anaesthetic Drug Trays
Authors: McGain F. , McAlister S. , McGavin A. , Story D.
Published: January 2019

We modelled the financial and environmental costs of two commonly used anaesthetic plastic drug trays. We proposed that, compared with single-use trays, reusable trays are less expensive, consume less water and produce less carbon dioxide, and that routinely adding cotton and paper increases financial and environmental costs. We used life cycle assessment to model the financial and environmental costs of reusable and single-use trays. From our life cycle assessment modelling, the reusable tray cost (Australian dollars) $0.23 (95% confidence interval [CI] $0.21 to $0.25) while the single-use tray alone cost $0.47 (price range of $0.42 to $0.52) and the single-use tray with cotton and gauze added was $0.90 (no price range in Melbourne). Production of CO2 was 110 g CO2 (95% CI 98 to 122 g CO2) for the reusable tray, 126 g (95% CI 104 to 151 g) for single-use trays alone (mean difference of 16 g, 95% CI -8 to 40 g) and 204 g CO2 (95% CI 166 to 268 g CO2) for the single-use trays with cotton and paper. Water use was 3.1 l (95% CI 2.5 to 3.7 l) for the reusable tray, 10.4 l (95% CI 8.2 to 12.7 l) for the single-use tray and 26.7 l (95% CI 20.5 to 35.4 l) for the single-use tray with cotton and paper. Compared with reusable plastic trays, single-use trays alone cost twice as much, produced 15% more CO2 and consumed three times the amount of water. Packaging cotton gauze and paper with single-use trays markedly increased the financial, energy and water costs. On both financial and environmental grounds it appears difficult to justify the use of single-use drug trays.
Torsade de Pointes in a Patient with Acute Prolonged QT Syndrome and Poorly Controlled Diabetes during Sevoflurane Anaesthesia
Authors: Thiruvenkatarajan V. , Osborn K. D. , van Wijk R. M. A. W. , Euler P. , Sethi R. , Moodie S. , Biradar V.
Published: January 2019

We report a case of torsade de pointes secondary to acute QT interval prolongation in a patient with poorly controlled diabetes mellitus towards the end of a laparoscopic nephrectomy under sevoflurane anaesthesia. The patient was successfully resuscitated and made a complete recovery. Our case suggests that acute QT interval prolongation should be considered in any patient with poor glycaemic control during prolonged procedures.
Sheehan's Syndrome Presenting as Postpartum Seizures
Authors: Jain G. , Singh D. , Kumar S.
Published: January 2019

We report a case where a patient presented with generalised tonic-clonic seizures secondary to nausea, vomiting and dehydration. She had suffered a postpartum haemorrhage six months previously. On laboratory assessment hyponatraemia and low hormone concentrations suggested pituitary failure. The diagnosis was confirmed by magnetic resonance imaging of the head, which showed a partially empty sella turcica. Given the severity of the morbidity in this case we emphasise that Sheehan's syndrome should be suspected in women presenting with postpartum seizures.
Unplanned Early Readmission to the Intensive Care Unit: A Case-Control Study of Patient, Intensive Care and Ward-Related Factors
Authors: Makris N. , Dulhunty J. M. , Paratz J. D. , Bandeshe H. , Gowardman J. R.
Published: January 2019

The purpose of this study was to identify patient, intensive care and ward-based risk factors for early, unplanned readmission to the intensive care unit. A five-year retrospective case-control study at a tertiary referral teaching hospital of 205 cases readmitted within 72 hours of intensive care unit discharge and 205 controls matched for admission diagnosis and severity of illness was conducted. The rate of unplanned readmissions was 3.1% and cases had significantly higher overall mortality than control patients (odds ratio [OR] 4.7, 95% confidence interval [CI] 2.1 to 10.7). New onset respiratory compromise and sepsis were the most common cause of readmission. Independent risk factors for readmission were chronic respiratory disease (OR 3.7, 95% CI 1.2 to 12, P=0.029), pre-existing anxiety/depression (OR 3.3, 95% CI 1.7 to 6.6, P <0.001), international normalised ratio >1.3 (OR 2.3, 95% CI 1.1 to 4.9, P=0.024), immobility (OR 2.3, 95% CI 1.4 to 3.6, P=0.001), nasogastric nutrition (OR 2.0, 95% CI 1.0 to 4.0, P=0.041), a white cell count >15×109/l (OR 2.0, 95% CI 1.2 to 3.4, P=0.012) and non-weekend intensive care unit discharge (OR 1.9, 95% CI 1.1 to 3.5, P=0.029). Physiological derangement on the ward (OR 26, 95% CI 8.0 to 81, P <0.001) strongly predicted readmission, although only 20% of patients meeting medical emergency team criteria had a medical emergency team call made. Risk of readmission is associated with both patient and intensive care factors. Physiological derangement on the ward predicts intensive care unit readmission, however, clinical response to this appears suboptimal.
Joseph Clover and the Cobra: A Tale of Snake Envenomation and Attempted Resuscitation with Bellows in London, 1852
Authors: Ball C.
Published: January 2019

The Industrial Revolution saw the creation of many new jobs, but probably none more curious than that of zookeeper. The London Zoological Gardens, established for members in 1828, was opened to the general public in 1847. In 1852 the “Head Keeper in the Serpent Room”, Edward Horatio Girling, spent a night farewelling a friend departing for Australia. He arrived at work in an inebriated state and was bitten on the face by a cobra that he was handling in a less than sensible manner.

He was taken by cab to University College Hospital where he was resuscitated by a number of doctors, including Joseph Clover, then the resident medical officer to the hospital and later to become the leading anaesthetist in London. Clover recorded this event in his diary along with the resuscitation method used. The patient eventually died but his treatment created a flurry of correspondence in the medical and lay press. Interestingly, the attempted resuscitation was with bellows, which had been abandoned by the Royal Humane Society twenty years earlier. Clover records other cases of resuscitation with bellows at University College Hospital during his time as a resident medical officer there (1848 to 1853).

There is a casebook belonging to Joseph Clover in the Geoffrey Kaye Museum, in Melbourne. This story is one of the many interesting stories uncovered during a study of this book and Clover's other personal papers.
Equipment to Manage a Difficult Airway during Anaesthesia
Authors: Baker P. A. , Flanagan B. T. , Greenland K. B. , Morris R. , Owen H. , Riley R. H. , Runciman W. B. , Scott D. A. , Segal R. , Smithies W. J. , Merry A. F.
Published: January 2019

Airway complications are a leading cause of morbidity and mortality in anaesthesia1. Effective management of a difficult airway requires the timely availability of suitable airway equipment. The Australian and New Zealand College of Anaesthetists has recently developed guidelines for the minimum set of equipment needed for the effective management of an unexpected difficult airway (TG4 [2010] www.anzca.edu.au/resources/professionaldocuments ). TG4 [2010] is based on expert consensus, underpinned by wide consultation and an extensive review of the available evidence, which is summarised in a Background Paper (TG4 BP [2010] www.anzca.edu.au/resources/professional-documents ). TG4 [2010] will be reviewed at the end of one year and thereafter every five years or more frequently if necessary. The current paper is reproduced directly from the Background Paper (TG4 BP [2010]).
Validation of the Postoperative Nausea and Vomiting Intensity Score in Gynaecological Patients
Authors: Allen M. L. , Leslie K. , Jansen N.
Published: January 2019

The Postoperative Nausea and Vomiting (PONV) Intensity Scale was developed to distinguish trivial from clinically important PONV perioperatively and has been validated in a general surgical population. This study aimed to assess the scale in gynaecological surgery patients.

Seventy-three patients undergoing gynaecological surgery were included. Interviews occurred at four and 24 hours postoperatively. Measurements included the PONV Intensity Scale, nausea and pain visual analogue scale, antiemetic use and complications related to PONV.

Ten patients (14%) had a clinically significant PONV Intensity Scale score, 42 (58%) reported nausea and 15 (21%) reported vomiting during the study. At 24 hours, 80% of patients with a clinically significant score at four hours had received antiemetics vs 18% of those without a clinically significant score (P=0.001). Of patients with a clinically significant score at 24 hours, 71% had suffered a complication vs 11% of those without a clinically significant score (P <0.0001). The median nausea visual analogue scale scores at four hours were 69 mm (interquartile range 69 to 76 mm) in patients with a clinically significant score vs 0 mm (0 to 9 mm) in patients without a clinically significant score (mean difference 56 mm, 95% confidence interval 41 to 72 mm, P <0.0001).

The PONV Intensity Scale is a valid, responsive and practically useful instrument in distinguishing trivial from clinically significant PONV. The rate of clinically important PONV is considerably lower than the rate of any PONV symptoms perioperatively.
Speeding Dantrolene Preparation for Treating Malignant Hyperthermia
Authors: Kugler Y. , Russell W. J.
Published: January 2019

Dantrolene is known to have a low solubility in water. Studies have demonstrated that it dissolves more rapidly in warm water. However, the overall benefit of warming has not been measured. This study evaluated the overall time benefit of warming.

The first step was to measure how long it took to warm the 10 ml plastic ampoules of sterile water from ambient temperature (20°C) to 45°C. We found that when immersed in a water bath held at 45°C, this required a minimum of seven minutes. Therefore the ampoules used for the study were kept immersed in a water bath held at 45°C for at least 10 minutes.

It took an average of 82.6 seconds to draw 60 ml (six ampoules) of water into a 60 ml syringe. Squirting the water into the dantrolene vial and mixing until dissolved took 102.8 seconds (SD 8.3) for the warmed water and 129.0 seconds (SD 14.6) for the ambient temperature water (P=0.009). Redrawing the dantrolene solution into the syringe took an average of 32 seconds for the warmed water and 35.2 seconds for the ambient temperature water. After the redrawing phase the average temperature of the warmed solution was 32.2°C. The average total preparation time for the warmed solution was 217.4 seconds (SD 20.0) and for the ambient temperature preparation was 243.0 seconds (SD 11.7) (P=0.038).

Thus the time difference in preparation was about 256 seconds, which is the time that could be saved in preparing the standard dose of 10 vials of dantrolene using water at 45°C. However, as it required about seven minutes to initially warm the sterile ampoules, there would be a net increase, not decrease in the time required. These findings indicate that warming is of no benefit in speeding dantrolene preparation.
Intensive Care Medicine Trainees’ Perception of Professionalism: A Qualitative Study
Authors: van Mook W. N. K. A. , de Grave W. S. , Gorter S. L. , Zwaveling J. H. , Schuwirth L. W. , van der Vleuten P. M.
Published: January 2019

The Competency-Based Training program in Intensive Care Medicine in Europe identified 12 competency domains. Professionalism was given a prominence equal to technical ability. However, little information pertaining to fellows’ views on professionalism is available.

A nationwide qualitative study was performed. The moderator asked participants to clarify the terms professionalism and professional behaviour, and to explore the questions “How do you learn the mentioned aspects?” and “What ways of learning do you find useful or superfluous?”. Qualitative data analysis software (MAXQDA2007) facilitated analysis using an inductive coding approach. Thirty-five fellows across eight groups participated. The themes most frequently addressed were communication, keeping distance and boundaries, medical knowledge and expertise, respect, teamwork, leadership and organisation and management. Medical knowledge, expertise and technical skills seem to become more tacit when training progresses. Topics can be categorised into themes of workplace-based learning, by gathering practical experience, by following examples and receiving feedback on action, including learning from own and others’ mistakes. Formal teaching courses (e.g. communication) and scheduled sessions addressing professionalism aspects were also valued.

The emerging themes considered most relevant for intensivists were adequate communication skills and keeping boundaries with patients and relatives. Professionalism is mainly learned ‘on the job’ from role models in the intensive care unit. Formal teaching courses and sessions addressing professionalism aspects were nevertheless valued, and learning from own and others’ mistakes was considered especially useful. Self-reflection as a starting point for learning professionalism was stressed.
End-of-Life Decisions in Hungarian Intensive Care Units
Authors: Zubek L. , Szabó L. , Diószeghy Cs. , Gál J. , élö G.
Published: January 2019

The awareness of local practice of end-of-life decisions in accordance with the law and ethical principles is essential for intensive care physicians in all countries. The first step for the required social dialogue is to investigate local practice.

We performed the first Hungarian survey with the aim of better understanding local practice in end-of-life decisions in intensive care units. Questionnaires were sent out electronically to 743 members of the Hungarian Society of Anaesthesiology and Intensive Care. Respecting anonymity, we have statistically evaluated 103 replies (response rate 13.8%) and compared the results to data from other European countries.

The results show that the practice of intensive care physicians in Hungary is rather paternalistic. Intensive care physicians generally make their decisions alone (3.75/5 points) without considering the opinion of the patient (2.57/5 points), the relatives (2.14/5 points) or other medical staff (2.37/5 points). Furthermore, they prefer not to start a form of treatment rather than to withdraw an ongoing one. Nevertheless, the frequency of end-of-life decisions (3 to 9% of intensive care unit patients) made in Hungarian intensive care units is less than in other European countries.

End-of-life decisions are part of medical practice. Since the legal and ethical framework is unclear, practice varies between locations and mostly depends on individual decisions rather than established protocols or guidance. For end-of-life decisions, self-determination must be supported and a dialogue must be established between lawmakers and physicians.
The Art of Providing Anaesthesia in Greek Mythology
Authors: Ntaidou T. K. , Siempos I. I.
Published: January 2019

We endeavored to thoroughly review Greek mythology and collect tales dealing with anaesthesia and myochalasis (paralysis). Among the evaluated sources were the poems of Hesiod, the epics of Homer, the tragedies of the great Athenian poets (namely Aeschylus, Sophocles and Euripides) as well as the contributions of several Latin writers, including Ovid. We found several examples of achieving hypnosis, analgesia and amnesia through the administration of drugs (inhaled or not) and music. Adverse events of drugs used for this purpose, such as post-anaesthetic emergence delirium, hallucinations, respiratory arrest and penis erection, were described in the presented myths. We noted that providing sleep was considered a divine privilege, although several mortals (mainly women) exhibited such powers as well. The concepts of sleep and death were closely associated in ancient classical thought. This review may stimulate anaesthetists’ fantasy and may help them realise the nobility of their medical specialty.
Frozen Blood Products: Clinically Effective and Potentially Ideal for Remote Australia
Authors: Holley A. , Marks D. C. , Johnson L. , Reade M. C. , Badloe J. F. , Noorman F.
Published: January 2019

The development of effective cryopreservation techniques for both red blood cells and platelets, which maintain ex vivo biological activity, in combination with frozen plasma, provides for a unique blood banking strategy. This technology greatly enhances the storage life of these products. The rationale and potential advantages of using cryopreservation techniques for the provision of blood products to remote and military environments have been effectively demonstrated in several conflicts over the last decade. Current haemostatic resuscitation doctrine for the exsanguinating patient supports the use of red blood cells, platelets and frozen plasma early in the resuscitation. We believe an integrated fresh–frozen blood bank inventory could facilitate provision of blood products, not only in the military setting but also in regional Australia, by overcoming many logistic and geographical challenges. The processes involved in production and point of care thawing are sufficiently well developed and achievable to make this technology a viable option. The potential limitations of cryopreservation and subsequent product thawing need to be considered if such a strategy is to be developed. A substantial body of international experience using cryopreserved products in remote settings has already been accrued. This experience provides a template for the possible creation of an Australian integrated fresh–frozen blood bank inventory that could conceivably enhance the care of patients in both regional Australia and in the military setting.
The Clinical Role of Glutamine Supplementation in Patients with Multiple Trauma: A Narrative Review
Authors: Al Balushi R. M. , Cohen J. , Banks M. , Paratz J. D.
Published: January 2019

Glutamine is considered an essential amino acid during stress and critical illness. Parenteral glutamine supplementation in critically ill patients has been shown to improve survival rate and minimise infectious complications, costs and hospital length-of-stay. However, glutamine supplementation in patients receiving enteral nutrition and the best method of administration are still controversial. The purpose of this article is to provide a narrative review of the current evidence and trials of enteral and parenteral glutamine supplementation in multiple trauma patients.

A search in PubMed and EMBASE was conducted and relevant papers that investigated the effect of enteral or parenteral glutamine supplementation in patients with multiple trauma were reviewed.

Although recent nutritional guidelines recommend that glutamine supplementation should be considered in these patients, further well-designed trials are required to provide a confirmed conclusion. Due to the inconclusive results of enteral glutamine supplementation trials in patients receiving enteral nutrition, future trials should focus on intravenous glutamine supplementation in patients requiring enteral nutrition and on major clinical outcome measures (e.g. mortality rate, infectious complications).
Breastfeeding after Anaesthesia: A Review of the Pharmacological Impact on Children
Authors: Chu T. C. , McCallum J. , Yii M. F.
Published: January 2019

Post-anaesthetic advice imparted to breastfeeding mothers can vary. This is due in part to the differing information from published data, product information sheets and inevitably from the unhindered flow of opinions available on the internet. This literature review examined the evidence relating to drugs commonly used in the modern anaesthetic setting and their impact on breastfed children. It suggests that special precautions are rarely warranted in the post-anaesthetic care of breastfeeding patients.
Financial and Environmental Costs of Manual versus Automated Control of End-Tidal Gas Concentrations
Authors: Tay S. , Weinberg L. , Peyton P. , Story D. , Briedis J.
Published: January 2019

Emerging technologies that reduce the economic and environmental costs of anaesthesia have had limited assessment. We hypothesised that automated control of end-tidal gases, a new feature in anaesthesia machines, will consistently reduce volatile agent consumption cost and greenhouse gas emissions. As part of the planned replacement of anaesthesia machines in a tertiary hospital, we performed a prospective before and after study comparing the cost and greenhouse gas emissions of isoflurane, sevoflurane and desflurane when using manual versus automated control of end-tidal gases. We analysed 3675 general anaesthesia cases with inhalational agents: 1865 using manual control and 1810 using automated control. Volatile agent cost was $18.87/hour using manual control and $13.82/hour using automated control: mean decrease $5.05/hour (95% confidence interval: $0.88–9.22/hour, P=0.0243). The 100-year global warming potential decreased from 23.2 kg/hour of carbon dioxide equivalents to 13.0 kg/hour: mean decrease 10.2 kg/hour (95% confidence interval: 2.7–17.7 kg/hour, P=0.0179). Automated control reduced costs by 27%. Greenhouse gas emissions decreased by 44%, a greater than expected decrease facilitated by a proportional reduction in desflurane use. Automated control of end-tidal gases increases participation in low-flow anaesthesia with economic and environmental benefits.
Spinal Pethidine for Elective Caesarean Section
Authors: Vassiliadis R. M. , Taylor P. G.
Published: January 2019

Pethidine (meperidine) is a unique member of the opioid family. In addition to its analgesic activity, it also has significant local anaesthetic activity. This property enables it to be used as the sole agent for spinal anaesthesia. We describe the successful use of intrathecal pethidine 1 mg/kg for an elective lower segment caesarean section in a patient presumed to be allergic to amide local anaesthetics. There were no significant adverse effects in either the mother or the newborn.
Eosinopenia as a Predictor of Unexpected Re-Admission and Mortality after Intensive Care Unit Discharge
Authors: Yip C. B. , Ho K. M.
Published: January 2019

Predicting unexpected intensive care unit (ICU) re-admission and mortality after critical illness is difficult. This study assessed the associations between eosinopenia on the day of ICU discharge and outcomes after critical illness. This retrospective cohort study involved a total of 1446 critically ill patients who survived their first ICU admission between January 2009 and March 2010 in a multidisciplinary ICU in Western Australia. Eosinopenia was defined as eosinophil count <0.01x109/l and the date of censor for survival was 31 October 2011. Of the 1446 patients included in the study, 106 patients (7.3%) were re-admitted to the ICU during the same hospitalisation and 178 patients died (12.3%) after ICU discharge. Eosinopenia at ICU discharge occurred in 130 patients (9.7%) and was more common among those who were subsequently re-admitted (18.6 vs 8.6%) or died after ICU discharge (22.5 vs 7.5%). Eosinopenia remained associated with ICU re-admission (odds ratio 2.50, 95% confidence interval 1.38–4.50; P=0.002) and post-ICU mortality (hazard ratio 2.65, 95% confidence interval 1.77–3.98; P=0.001) after adjusting for age, gender, nocturnal discharge, neutrophil count at ICU discharge, elective surgical admission, Sequential Organ Failure Assessment scores, Acute Physiology and Chronic Health Evaluation II predicted mortality and chronic medical diseases. Eosinopenia at ICU discharge explained about 8.4% of the variability and was the third most important factor in explaining the variability in survival after ICU discharge. In summary, eosinopenia at ICU discharge was associated with an increased risk of unexpected ICU re-admission and post-ICU mortality.
The Association between Sedation Practices and Duration of Mechanical Ventilation in Intensive Care
Authors: Jarman A. M. , Duke G. J. , Reade M. C. , Casamento A.
Published: January 2019

Choice of sedation agent may influence duration of mechanical ventilation in the intensive care unit (ICU). We conducted a retrospective observational analysis of 2102 consecutive mechanically ventilated ICU patients over an eight-year period at a Melbourne metropolitan hospital with a ten-bed general ICU to determine if propofol was associated with shorter duration of mechanical ventilation (MV) than midazolam.

Data were extracted from the hospital administrative database, pharmacy supply order records and ICU database, to calculate rates of MV and tracheostomy, length-of-stay, propofol and midazolam infusion doses, illness severity and casemix and use of ‘sedation scores’ and ‘sedation break’ respectively. The primary end-points were duration of MV, tracheostomy rate and hospital outcome. Negative binomial regression and logistic regression were used to identify temporal trends.

From 1 July 2002 to 30 June 2010 there were 5751 ICU admissions including 2102 (36.6%) with MV. Over this period there was a 70% decline in annual midazolam use and a greater than fivefold rise in propofol use. ‘Sedation scoring’ and ‘sedation break’ procedures were introduced from 2006. Over the eight-year observation period there were significant increases in the numbers of annual MV admissions and long-term (>96 hours) MV patients, but a decline in median duration of MV, tracheostomy rate, median ICU length-of-stay and median hospital length-of-stay. All temporal trends were significant ( P < 0.05). The temporal association with changes in sedation management practice, including primary sedative agent choice during MV, may explain these findings.
How do Anaesthetists in New Zealand Disseminate Critical Airway Information?
Authors: Baker P. A. , Moore C. L. , Hopley L. , Herzer K. R. , Mark L. J.
Published: January 2019

The communication of information concerning patients with difficult airways is universally recognised as an important component in avoiding future airway management difficulties. A range of options is available to impart this information; little is known however, about the follow-up patterns of anaesthetists following the identification and management of a difficult airway. In this study, 158 anaesthetists were contacted and asked to comment on their follow-up patterns regarding a number of difficult airway scenarios. This was followed by a retrospective survey of 124 patients with known difficult airways. A wide discrepancy was found between stated follow-up preferences by anaesthetists and the actual use of options such as postoperative visits, notes in the clinical record, letters to the patient and family doctor, and entries in hospital, national and MedicAlert™ databases. Of the patients with an airway difficulty noted on their anaesthetic record, only 14% of them also had a pertinent comment on their clinical record; even fewer were referred to hospital warning systems (12%) or national (6%) and MedicAlert (7%) databases.

Comments from our survey were critical of multiple difficult airway databases and alert systems, which are not linked and do not lead automatically to a single source of information. We suggest that a custom-designed MedicAlert New Zealand difficult airway/intubation registry could be established, with easy access for medical practitioners and patients. This registry could be accessed through the National Health Index database and linked to the MedicAlert international registry and their nine international affiliates.
Has the Middle-Level Anaesthesia Manpower Training Program of the West African College of Surgeons Fulfilled its Objectives?
Authors: Bode C. O. , Olatosi J. , Amposah G. , Desalu I.
Published: January 2019

An audit of the West African College of Surgeons’ middle-level Diploma in Anaesthesia program was carried out to determine the current status of the diplomates. Using the West African College of Surgeons’ database, social media and personal communications, the current status of Diploma in Anaesthesia graduates spanning 20 years was determined.

A total of 303 (97%) out of 311 of graduates were traced. Eighty percent were still practising anaesthesia, while 5% were now in other disciplines. Two hundred and four (67.3%) still resided in West Africa (183 in Nigeria, 50 in Ghana, one in Sierra Leone), while 69 (22.7%) were abroad: 35 (11.5%) in the United Kingdom, 21 (6.9%) in the United States of America and four (1.3%) in Canada. More Ghanaian than Nigerian graduates had emigrated (41 vs 14%, respectively). Only 9% of diplomates remained in rural communities (as originally envisaged), while 31% were now consultants (as fellows) and 30% were registrars in fellowship training.

These findings indicate that most diplomates moved on to acquire further qualifications and a significant proportion migrated. The program did not appear to have achieved the objectives of meeting rural middle-level manpower needs in anaesthesia as envisaged. It has, however, boosted the recruitment drive for residency training in anaesthesia. Perhaps a less migrant cadre such as nurses may better serve this function if recruited into a suitably designed training program in countries desiring to use middle-level manpower in anaesthesia.
Outcomes in Critical Care Delivery at Jimma University Specialised Hospital, Ethiopia
Authors: Smith Z. A. , Ayele Y. , Mcdonald P.
Published: January 2019

The aim of this study was to assess outcomes following intensive care unit (ICU) admissions at Jimma University Specialised Hospital, Ethiopia. This was a retrospective observational study. Data were collected regarding all ICU admissions and discharges during a 12-month period beginning August 2011. Demographic data and information regarding diagnosis, length-of-stay and outcome were gathered and data analysed. There were 370 admissions to the ICU during the study period. Median age (interquartile range) was 32.0 (22.0–47.0) years and 56.2% were males. The median length-of-stay (interquartile range) was 3.0 (1.0–7.0) days. The overall ICU mortality rate was 50.4% and major causes included trauma, cardiac disease, acute abdominal presentations, septic shock, tetanus and hysterectomy secondary to uterine rupture. Medical diagnoses accounted for 50.1% of admissions followed by surgery (43.2%) and obstetrics (5.8%). Corresponding mortality rates were 53.6, 48.0 and 42.9%, respectively. The main cause for surgical admission was trauma, with head injury carrying a mortality of 52.1%. The principal cause for medical admission was cardiac disease. In children, trauma, upper airway obstruction and communicable diseases were most common. Critical care mortality rates at this Ethiopian university hospital reflect the challenges facing critical care delivery in the developing world. Delayed presentation to hospital secondary to poor access to healthcare plays a predominant role. This is confounded by inadequate staffing, training, diagnostic and interventional limitations. Despite resource restraints, simple cost-effective measures may improve morbidity and mortality.
Post-Cardiac Surgery Thrombotic Thrombocytopenic Purpura with Digital Ischaemia
Authors: Weinberg L. , Chang J. , Hayward P. , Reynolds M. , Fernandes J.
Published: January 2019

We report a case of thrombotic thrombocytopenic purpura in a woman post mitral valve repair who presented with unexplained thrombocytopenia, intermittent fever, acute renal failure and severe digital ischaemia. The diagnosis of thrombotic thrombocytopenic purpura was confirmed after exclusion of many of the aetiological factors of postoperative digital ischaemia, a positive haemolytic screen and blood film examination which showed schistocytes and fragmented red cells. Plasma ADAMTS-13 activity measured by enzyme-linked immunosorbent assay was reduced. Treatment of thrombotic thrombocytopenic purpura with exchange plasmapheresis and methylprednisolone was of paramount importance and the patient was discharged home on day 30 with complete recovery of haematological, neurological and renal function. In order to increase the awareness of this rare multisystem process, we report our experience in managing this life-threatening condition. Our discussion covers the diagnostic challenges, theories on aetiology, pathogenesis and treatment of this condition in the context of cardiac surgery.
Intraoperative Awake Tracheal Intubation Using the Airway Scope™ in Caesarean Section
Authors: Kariya N. , Kimura K. , Iwasaki R. , Ueki R. , Tatara T. , Tashiro C.
Published: January 2019

The Airway Scope™, a novel videolaryngoscope used for tracheal intubation, is minimally invasive and can be used in conscious patients. The parturient with a potentially difficult airway should sometimes be intubated while awake, without anaesthesia or neuromuscular block. Two pregnant women who experienced massive postpartum haemorrhage during caesarean section underwent unscheduled intraoperative tracheal intubation using the Airway Scope. They were conscious and were intubated with minimal local anaesthesia so as to prevent cardiovascular compromise. We believe the Airway Scope is useful for anaesthetic procedures in the parturient who has haemodynamic instability.
Acute Respiratory Distress Syndrome: Current Concepts and Future Directions
Authors: Fröhlich S. , Murphy N. , Ryan D. , Boylan J. F.
Published: January 2019

Acute respiratory distress syndrome is one of the leading causes of death in critically ill patients. Recent advances in supportive care have led to a moderate improvement in mortality. In particular, a much lower mortality rate than expected was evident in the severest category of patients (requiring extracorporeal membrane oxygenation) in Australia during the recent H1N1 pandemic.

Though improvements in supportive care may have provided some benefit, there remains an absence of effective biological agents that are necessary to achieve further incremental reduction in mortality. This article will review the evidence available for current treatment strategies and discuss future research directions that may eventually improve outcomes in this important global disease.