bluuebunny/crossref_metadata_2025 huggingface dataset:
Postoperative Epidural Fentanyl Infusion—is the Addition of 0.1% Bupivacaine of Benefit?
Authors: Paech M. J. , Westmore M. D.
Published: January 2019

A randomised, double-blind controlled clinical trial was conducted in 90 women scheduled for major abdominal gynaecological oncology surgery to determine the effect of adding 0.1% plain bupivacaine to a thoracic epidural fentanyl infusion. Following combined epidural and general anaesthesia, patients were randomised to receive epidural fentanyl 10 μg/ml, with (group FB) or without (group F) bupivacaine. After an initial 50 μg bolus of fentanyl, infusion rate was adjusted according to need between 2 and 10 ml/hr for 48 hours.

The two groups (n = 40) were similar with regard to age, weight and preoperative status. Analgesia both at rest and with movement were significantly better in group FB (P <0.0001) during the first 24 hours postoperatively, the greatest difference occurring in the 4 to 16 hour period. There was no significant difference between groups from 24 to 48 hours postoperatively. Fentanyl utilisation was significantly lower in group FB (median 41 versus 53 μg/hr, P <0.001), although clinically the fentanyl dose-sparing effect of bupivacaine was small and did not reduce opioid-induced side-effects. There was no significant difference between groups with respect to side-effects or lower limb weakness, although fewer patients in group FB could be mobilised on the morning of the first postoperative day (P <0.01). Nevertherless, all study patients were ambulant by the same afternoon.

We concluded that, in this patient population, the addition of 0.1% bupivacaine to a thoracic epidural fentanyl infusion was beneficial in the early postoperative period.
Intraoperative and Postoperative Analgesia Using Intravenous Opioid, Clonidine and Lignocaine
Authors: de Kock M. , Lavandhomme P. , Scholtes J. L.
Published: January 2019

The postoperative analgesia afforded after colonic surgery by IV opioid, clonidine and lignocaine given intra- and postoperatively was evaluated. In a double-blind randomised trial, 80 male patients scheduled for colonic resection under general anaesthesia received fentany 15 μg.kg−1 at induction and another 4 μg.kg−1 before skin incision (group A) or fentanyl (same dose) plus clonidine 4 μg.kg−1 in 20 min + 2 μg.kg−1.h−1 (group B, C) or fentanyl plus clonidine (same dosage) plus lignocaine 2 mg.kg−1 before skin incision, repeated before peritoneal incision and retractor placement (group D). In the four groups, intraoperative boluses of fentanyl 2 μg.kg−1 were given in response to the painful stimulation of the procedure. Postoperative pain was managed with PCA delivering 2 mg morphine per request in group A, 1.5 mg morphine in group B, 1.5 mg morphine + 15 μg clonidine in group C and 1.2 mg morphine + 15 μg clonidine + 23 mg lignocaine in group D.

Postoperative analgesia was assessed by recording the analgesic demands (met and unmet) and the dose of morphine delivered at 6, 12, 18, 24, 36 hours. Side-effects, pain and sedation analogue scores were also recorded. A nalgesic demands and delivered morphine dose were reduced, at any time interval considered, in groups B, C, D, compared with A (P <0.001). No differences were noted between the groups B, C, D. Pain analogue scores were better in groups B, C, D compared with group A (P <0.001). Sedation and side-effects were not increased in groups B, C, D.

Intraoperative clonidine was the major determinant of the reduction in analgesic demands and morphine delivered. Lignocaine, at the dose used, failed to afford any additional benefit.
Intramuscular Ketorolac for Postoperative Analgesia following Laparoscopic Sterilisation
Authors: Shapiro M. H. , Duffy B. L.
Published: January 2019

The analgesic effect of intramuscular ketorolac was assessed by double blind study in forty women presenting for day-case laparoscopic sterilisation. The patients were randomly allocated to receive either ketorolac 30 mg or saline by intramuscular injection immediately following induction of general anaesthesia. There was no statistically significant difference between the groups in pain scores, opioid requirements or incidence of nausea and vomiting in the postoperative period. In view of the potential side-effects of ketorolac, and the apparent lack of efficacy when used prophylactically, the routine use of the drug in this group of patients cannot be recommended.
Indomethacin as Adjunct Analgesia following Open Cholecystectomy
Authors: Turner G. A. , Gorringe J.
Published: January 2019

Fifty patients scheduled for elective cholecystectomy were randomised to receive either indomethacin suppositories 200 mg p.r. at the end of anaesthesia, followed by 100 mg bd for three days, or placebo supppositories according to the same regimen. All patients were given intravenous pethidine via patient-controlled analgesia (PCA) postoperatively. The mean dose of pethidine required by the patients in the indomethacin group was significantly less than that used by the placebo group, the cumulative dose after three days being 530.7 mg (SD 664.0) and 1151.0 mg (682.0) for the indomethacin and placebo groups respectively. At the same time the patients in the indomethacin group had lower pain scores both at rest and with movement, though this was only statistically significant on the first day on movement. There was no statistical difference between the groups with respect to the incidence of nausea, indigestion, proctitis, volume of drainage from the wound drain, or width of bruising around the wounds. Serum creatinine levels were compared pre- and postoperatively where possible and showed no change in either group.
The Effect of Sustained Positive Airway Pressure on Derived Cardiac Output in Children
Authors: Clough J. B. , Duncan A. W. , Sly P. D.
Published: January 2019

It is well established that the improvement in gas exchange that occurs with positive pressure ventilation may come at the expense of a decrease in cardiac output and oxygen delivery. Clinical observation suggests that children and infants may be more resistant than adults to the falls in cardiac output induced by positive airway pressure. The aims of this study were to quantify the effect of a sustained increase in intrathoracic pressure on cardiac output and stroke volume, and to determine whether this change is age-related. Twenty-eight children undergoing general anaesthesia were studied. Cardiac output was derived using pulsed wave Doppler techniques at four different levels of sustained positive airway pressure, and stroke volume was calculated. The relationship between airway pressure and both cardiac output and stroke volume was examined using a general linear model which included age as a continuous variable. Cardiac output decreased with increasing levels of sustained positive airway pressure (P=0.001). The fall in SV for a given airway pressure increased with increasing age (P=0.02). The mechanisms responsible for the increase of the magnitude of the fall in stroke volume with age remain to be elucidated.
Postoperative Apnoea in Infants
Authors: Sims C. , Johnson C. M.
Published: January 2019

Past studies concerning postoperative apnoea in infants were identified and reviewed. A total of only 200 former preterm infants having minor surgery under general anaesthesia have been prospectively studied. The incidence of apnoea after general anaesthesia is approximately 30%, and is inversely related to postconceptual age. A large number of term infants have been studied, and the incidence of postoperative apnoea is very low. The initial apnoea is always within 12 hours of surgery, though only one study has collected data beyond this length of time. Past history of apnoea episodes, bronchopulmonary dysplasia, anaemia or neurological disease may be associated with an increased risk, though current evidence is not strong. No patient characteristic apart from postconceptual age has enough sensitivity and specificity to identify a high-risk group. The use of spinal anaesthesia or methylxanthines may reduce the incidence of postoperative apnoea, but again the evidence is not strong. Recommendations concerning the timing of elective surgery and the use of postoperative respiratory monitoring in the former preterm infant can only be made cautiously in view of the paucity of data on which to base them.
A Written Guideline Implementation Can Lead to Reductions in Laboratory Testing in an Intensive Care Unit
Authors: Mehari S. M. , Havill J. H. , Montgomery C.
Published: January 2019

The impact of developing guidelines for laboratory testing in an Intensive Care Unit (ICU) was examined. Targeted blood tests were recorded on fifty cardiac surgery and fifty general intensive care patients retrospectively. Following the introduction of guidelines, the study was repeated with prospective data collection. Comparison of the samples before and after the intervention showed a 25.9% reduction in all blood tests and a 17.1% reduction in arterial blood gases in the post cardiac surgery group. In general ICU patients, the drop in all tests was 16.6% and in arterial blood gases 21.9%. The cost savings from the cardiac surgery sample was N.Z.$3,637 and general ICU N.Z.$3,166, giving a sum total of N.Z.$6,803 in 100 patients. The potential cost savings for the annual admissions of 1,200 patients is N.Z.$81,636. This study shows that written guidelines can bring about major cost reduction in the short-term.
A Prospective Clinical Comparison of Two Intravenous Polyurethane Cannulae
Authors: Russell W. J. , Micik S. , Gourd S. , Mackay H. , Wright S.
Published: January 2019

Tissue irritation, as evidenced by phlebitis, associated with Optiva™ (Johnson & Johnson Medical) and Insyte™ (Becton Dickinson) polyurethane cannulae was studied. The integrity of the cannulae on removal, the incidence of infection at the cannula site and the factors which influence phlebitis were also examined.

One thousand and eight patients had a polyurethane cannula placed for induction of anaesthesia for cardiac surgery. After surgery, the cannula was examined every 24 hours. If evidence of phlebitis occurred, the cannula was removed and sent for culture. All remaining cannulae were removed at 72 hours and the site examined daily for a further three days.

There were 503 Optiva™ and 505 Insyte™ cannulae studied. The distributions between the two cannulae with respect to patient characteristics, gauge of cannula, number of attempts and difficulty of insertion, cannula site and anaesthetist inserting were similar. The early removal rate for both groups was 47%.

Overall phlebitis rate with Optiva™ was 31% and Insyte™ 33%. This difference is not statistically significant. The cumulative phlebitis rate increased with time but did not differ between the two types of cannulae.

Minor tip distortion or shaft kinking of the cannulae occurred in 16.2% of Optiva™ and 23.5% of Insyte™. This difference is statistically significant and may relate to the slightly more acute taper at the Optiva™ cannula tip. Both cannulae were similar in clinical performance.
Report of the Anaesthetic Mortality Committee of Western Australia 1990-1995
Authors: Eagle C. C. P. , Davis N. J.
Published: January 2019

The structure and function of the Anaesthetic Mortality Committee of Western Australia are described. Reports of 500 deaths from 1990 to 1995 are analysed and discussed. The Committee determined that, in 21 cases, anaesthesia played a significant part in the death of the patient. These cases are further analysed. Deaths due mainly to anaesthetic factors are estimated to occur once in every 40,000 operations in Western Australia. One or two otherwise healthy people die each year in Western Australia from an anaesthetic mishap.
Amrinone versus Dobutamine in Cardiac Surgical Patients with Severe Pulmonary Hypertension after Cardiopulmonary Bypass: A Prospective, Randomized Double-Blinded Trial
Authors: Jenkins I. R. , Dolman J. , O'Connor J. P. , Ansley D. M.
Published: January 2019

We compared the relative effects of dobutamine (5 μg/kg/min) and amrinone (1.0 mg/kg bolus followed by 10 μg/kg/min) on right and left ventricular function and pulmonary arterial pressures during weaning from cardiopulmonary bypass in patients with a mean preoperative pulmonary pressure >30 mmHg. Twenty patients scheduled for mitral valve replacement were studied in a prospective, randomized, double-blind trial.

Patients receiving amrinone had a greater increase in cardiac index (CI) of 1.38 (±0.95) litre/min/m2 at separation vs 0.69 (±0.63) litre/min/m2 in the dobutamine group (P<0.05). The amrinone group also had a greater increase in right ventricular ejection fraction (0.15±0.08 at separation from cardiopulmonary bypass versus an increase of 0.04 ±0.11 in those receiving dobutamine; P<0.005). Amrinone produced a larger decrease in pulmonary artery wedge pressure 8.0 (±4.4) mmHg vs 0.75 (±6.6) mmHg at separation; pulmonary artery systolic and diastolic pressures also were reduced more in the amrinone group. There were no differences in heart rate, mean arterial pressure, central venous pressure and right ventricular stroke work index between patient groups.

In the doses chosen, the use of amrinone compared to dobutamine was associated with a reduction in pulmonary arterial pressures and an increase in cardiac index and right ventricular ejection fraction after separation from bypass in patients with severe preoperative pulmonary hypertension.
Does Local Anaesthetic Affect the Success Rate of Intravenous Cannulation?
Authors: Holdgate A. , Wong G.
Published: January 2019

We aimed to assess whether subcutaneous lignocaine affects the success rate of intravenous cannulation using a randomized clinical trial. Pre-prepared cannulation packs, 50% containing local anaesthetic, were used to cannulate consecutive consenting patients presenting to the Emergency Department who required cannulation as part of their routine treatment. Doctors with less than four years postgraduate experience randomly selected a pack to perform cannulation and completed a data collection form after each cannulation.

Eighty-seven patients received lignocaine with 73 (83.9%) successfully cannulated on the first attempt, 79 patients were cannulated without lignocaine with 64 (81%) successfully cannulated on the first attempt. Subcutaneous lignocaine did not significantly affect the success rate of intravenous cannulation on the first attempt (P=0.5).

Subcutaneous lignocaine has been shown to significantly reduce the pain of intravenous cannulation. This study supports the use of local anaesthesia for all routine venous cannulation.
Safety and Efficacy of Target Controlled Infusion (Diprifusor™) vs Manually Controlled Infusion of Propofol for Anaesthesia
Authors: Hunt-Smith J. , Donaghy A. , Leslie K. , Kluger M. , Gunn K. , Warwick N.
Published: January 2019

In this multi-centre, randomized trial, we compared the safety and efficacy of Diprifusor™ TCI with manually controlled infusion (MCI) of propofol for anaesthesia. With approval, 123 adult male and female patients were studied. Firstly, each investigator anaesthetized five patients to familiarize themselves with Diprifusor™ TCI. In Stage 2, 98 patients were randomized to receive propofol-based anaesthesia via TCI or MCI. Adjuvant drugs, airway management and monitoring were managed at the discretion of the anaesthetist. Results are presented as mean (SD). Induction times were significantly longer [67 (32) vs 54 (17)s] and induction doses were significantly lower [14 (5) vs 16 (4) ml] in the TCI vs the MCI group. Recovery times and total doses were not significantly different. There were statistically but not clinically significant differences in mean arterial blood pressure and heart rate. Quality of anaesthesia and ease of control of anaesthesia were similar. We conclude that Diprifusor™ TCI and MCI are similar in terms of safety and efficacy.
Disseminated Intravascular Coagulation in a Patient Undergoing Removal of Humeral Head for Pain Relief
Authors: Terasako K.
Published: January 2019

Disseminated intravascular coagulation (DIC) was recently observed intraoperatively in a patient who required removal of her right humeral head for pain relief. Despite normal preoperative coagulation parameters, the patient developed wound oozing soon after suturing the skin. Coagulation profile revealed decreased platelets, plasma coagulation factors and fibrinogen in association with elevated fibrin degradation products. To manage the DIC, urinastatin and gabexate mesilate, along with blood component replacement, proved effective.
Lower Limb Compartment Syndrome Resulting from Malignant Hyperthermia
Authors: Johnson I. A. T. , Andrzejowski J. C. , Currie J. S. A.
Published: January 2019

We report a case of compartment syndrome complicating malignant hyperthermia (MH) in a previously healthy patient. An intraoperative MH crisis responded to treatment with intravenous dantrolene. The patient subsequently developed a lower limb compartment syndrome which required fasciotomy.

Recognition of the link between MH and compartment syndrome helps ensure prompt diagnosis and treatment of this rare complication of MH.
Caffeine Overdose in a Premature Infant: Clinical Course and Pharmacokinetics
Authors: Anderson B. J. , Gunn T. R. , Holford N. H. G. , Johnson R.
Published: January 2019

The elimination of caffeine was investigated in a 1860 g, 31 week gestation neonate, following the accidental administration of a 160 mg.kg−1 dose. The first serum concentration measured was 217.5 mg.l−1 at 36.5 h after dosing. Fitting of time-concentration data was performed using non-linear regression with MKMODEL. A first order elimination model was superior to a mixed order model. Parameter estimates were: clearance 0.01 l.h−1, volume of distribution 1.17 litres, elimination half-life 81 h. Toxic manifestations included hypertonia, sweating, tachycardia, cardiac failure, pulmonary oedema and metabolic disturbances (metabolic acidosis, hyperglycaemia and creatine kinase elevation). An unusual feature of this infant's illness course was gastric dilatation. These signs resolved by day 7 at a serum concentration of 60–70 mg.l−1.

Caffeine clearance has traditionally been reported as either an absolute value or as directly proportional to body weight. The per kilogram model gives an erroneous impression that clearance is greatest in early childhood and then decreases with age until adult rates are reached in late adolescence. Age-related clearance values reported in the literature were reviewed using an allometric 3/4 power model. This size model demonstrates that clearance increases in infancy and reaches adult rates within the first three months of life.
A Prospective Randomized Clinical Assessment of a New Pigtail Central Venous Catheter in Comparison with Standard Alternatives
Authors: Merry A. F. , Webster C. S. , Van Cotthem I. C. , Holland R. L. , Beca J. S. , Middleton N. G.
Published: January 2019

The Cook Pigtail central venous catheter (CVC) has been designed to diminish the risk of vascular perforation and consequent cardiac tamponade. With the participation of 12 consultant anaesthetists and 19 registrars, adults undergoing elective surgery were randomized to receive either a Pigtail (n=101) or their consultant anaesthetists’ “standard” CVC (n=102). Median ease of insertion was rated 8 for Pigtail CVCs and 9 for standards (10 being best; P=0.001). Arrhythmias occurred during 16 standard and 33 Pigtail central venous catheter insertions (P<0.006). No significant difference was found in insertion time or radiographically assessed tip depth for standard and Pigtail central venous catheters. A perforated right atrium of uncertain cause occurred in a patient who received an Arrow triple-lumen central venous catheter. Participating consultant anaesthetists preferred their “standard” central venous catheter for routine use, but five indicated that they would select a Cook Pigtail where long-term use was planned because of in vitro evidence of its greater safety.
Effect of Positive End-Expiratory Pressure on Left and Right Ventricular Diastolic Filling Assessed by Transoesophageal Doppler Echocardiography
Authors: Yamada T. , Takeda J. , Satoh M. , Koyama K. , Hashiguchi S. , Yokoi M.
Published: January 2019

The effect of positive end-expiratory pressure (PEEP) on left and right ventricular diastolic filling dynamics was assessed by transmitral and transtricuspid flow patterns. Using transoesophageal Doppler echocardiography in fourteen ASA physical status 1 female patients, the following measurements were performed at baseline (0 cmH2O PEEP) and at 5, 10, 15, and 20 cmH2O PEEP: 1. peak velocity of early filling (peak E velocity), 2. peak velocity of atrial contraction (peak A velocity), 3. the ratio of the peak E to A velocity (peak E/A velocity ratio), 4. isovolumic relaxation time (IRT), 5. acceleration half-time (AHT), 6. deceleration half-time (DHT) of early filling, and 7. end-diastolic and end-systolic areas of both ventricles. Increasing PEEP progressively deceased peak E velocity of both ventricles. In contrast, peak A velocity did not change and the peak E/A velocity ratio decreased significantly with PEEP. IRT and AHTs remained unchanged, but DHTs of both ventricles increased following PEEP. End-diastolic and end-systolic areas of both ventricles decreased gradually and significantly with PEEP. It is concluded that PEEP was associated with decreased preload as well as reduced compliance of both ventricles, which was considered to contribute to the changes in diastolic ventricular filling.
Cisatracurium and Atracurium as Antigens
Authors: Fisher M. McD.
Published: January 2019

Seventy-five consecutive patients referred to an anaesthetic allergy clinic were intradermally tested with atracurium and cisatracurium. With the exception of one patient the results were identical, suggesting that allergy to either drug is associated with allergy to the stereoisomer. For skin testing for allergy to neuromuscular blocking drugs it is only necessary to use either atracurium or cisatracurium and cisatracurium is the preferred drug.
The Impact of an Acute Pain Service on Postoperative Pain Management
Authors: Sartain J. B. , Barry J. J.
Published: January 2019

An audit of postoperative pain management was conducted before and after the introduction of an Acute Pain Service (APS) run entirely by medical staff. The ability of patients to complete two pain-scoring systems, a verbal rating score (VRS) and a numerical rating score (NRS, where 0=nopain, 10=worst pain) was compared. We surveyed 605 adults 24 hours postoperatively. For major operations, the incidence of “severe” or “unbearable” pain at rest (VRS) over the first 24 hours decreased from 18.1% before to 3.5% after the APS (P=0.0002) and severe/unbearable pain with movement decreased from 50% to 31% (P=0.0037). The average NRS pain scores fell from 4.65 to 3.37 at rest (P<0.0001) and from 6.77 to 6.19 with movement (P=0.046). The incidence of severe/unbearable pain at rest with patient-controlled analgesia (PCA) decreased from 19.7% to 3.2% after the APS (P=0.0012) and with movement from 51.3% to 35.1% (P=0.049). For epidural analgesia, severe/unbearable pain at rest was 18.8% prior to the APS and 4.4% after (P=0.14), and with movement was 43.8% before and 19.1% after (P=0.079).

The NRS pain-scoring system was unsuitable for Aboriginal or Torres Strait Islander patients. Patient satisfaction was high both before and after the introduction of the APS, and was an unreliable indicator of effective pain relief. We conclude that an APS can improve postoperative pain control with PCA and epidural analgesia.
Extracorporeal Circulatory Support in Near-Fatal Flecainide Overdose
Authors: Corkeron M. A. , Van Heerden P. V. , Newman S. M. A. J. , Dusci L.
Published: January 2019

Flecainide, a class 1c antiarrhythmic, has a high mortality associated with significant overdose. We report the case of a 20-year-old female who took approximately 4 grams of flecainide and a small amount of paracetamol as an impulsive gesture. Circulatory failure unresponsive to pacing, inotropes and sodium bicarbonate was successfully treated with cardiopulmonary bypass (CPB). Resolution of her myocardial failure occurred over 24 hours and she was weaned from CPB 30 hours after its initiation. Coagulopathy and intravascular haemolysis were apparent during bypass and necessitated substantial use of blood products. Ischaemic renal dysfunction manifested early in her admission and required haemodiafiltration. Despite a prolonged period of unresponsiveness and pupillary dilatation during resuscitation and CPB she made a full recovery. We believe this is the first reported case of flecainide overdose, requiring extracorporeal circulatory support, not resulting in neurological deficit.
Management of a Pregnant Patient with Airway Obstruction Secondary to Goitre
Authors: Reid A. W. , Warmington A. D. L. , Wilkinson L. M.
Published: January 2019

A case of airway obstruction in advanced pregnancy is presented. The patient was successfully managed with an awake fibreoptic intubation performed orally followed by a caesarean section and thyroidectomy as a combined procedure. On resection, a thyroid gland weighing 370g was removed. The patient made an uneventful recovery.
Gas Embolism Produced by Hydrogen Peroxide Abscess Irrigation in an Infant
Authors: Schwab C. , Dilworth K.
Published: January 2019

The production of gaseous oxygen when hydrogen peroxide interacts with tissue is a well-known phenomenon that has been reported as a rare cause of gas embolism. We present the case of an 11-month-old infant who sustained an immediate cardiorespiratory arrest following the use of this agent during a minor surgical procedure. Clinical features, radiological findings and the rapid response to resuscitation were strongly suggestive of major gas embolism. Adverse effects of inappropriate use of hydrogen peroxide, and the diagnosis and management of these problems are discussed.
Pulsed-Field Gel Electrophoresis is a Useful Tool in the Monitoring of Methicillin-Resistant Staphylococcus Aureus Epidemic Outbreaks in the Intensive Care Unit
Authors: Cameron R. J. , Ferguson J. K. , O'Brien M. W.
Published: January 2019

We wished to determine how pulsed-field gel electrophoresis may be of use in monitoring methicillin-resistant Staphylococcus aureus (MRSA) outbreaks in the intensive care unit (ICU). A retrospective epidemiological analysis was conducted. All 27 ICU patients and 11 patients from other hospital wards from whom MRSA was isolated over a one year period were included in the study. Seventeen of the 27 ICU MRSA isolates were analysed by pulsed-field gel electrophoresis for clonality and compared with the 11 other hospital isolates genotypes over the same period. During three MRSA outbreaks, five MRSA genotypes were identified in ICU whilst the same five genotypes and three additional were found in the rest of the hospital. Pulsed-field gel electrophoresis analysis was useful in identifying clonality of ICU MRSA infections and establishing that they were imported from hospital wards, rather than arising de novo in ICU. We were further able to identify clonal clusters within the unit linked by temporal and geographical proximity, suggestive of cross-infection. Pulsed-field gel electrophoresis typing might be additionally useful in tracing the source of human and/or environmental factors if a genotype were persistently identified.
Anaesthetic Management of Patients Undergoing Lung Volume Reduction Surgery for Treatment of Severe Emphysema
Authors: Liu E. H. C. , Gillbe C. E. , Watson A. C.
Published: January 2019

Lung volume reduction surgery can improve lung function in patients with emphysema. We report our anaesthetic experience, problems and the physiological data of eight patients. Our aims were prevention of air trapping and air leaks, good analgesia and early recovery and mobilization. We were able to achieve these aims using pressure limited ventilation, lumbar epidural diamorphine, propofol infusions and intensive physiotherapy. Hypoxia during one-lung ventilation was the main intraoperative problem. Air leaks, infection and pulmonary hypertension were the main postoperative problems.
Reduction of Preoperative Investigations with the Introduction of an Anaesthetist-led Preoperative Assessment Clinic
Authors: Power L. M. , Thackray N. M.
Published: January 2019

Preoperative investigations, when used to screen for disease not clinically evident, have been shown to be unnecessary. The aim of this study was to rationalize the ordering of preoperative investigations by introducing guidelines and screening all investigations ordered at a new Day of Surgery Admissions clinic. Two hundred and one elective general and ear, nose and throat (ENT) patients attending this clinic at Sir Charles Gairdner Hospital from July to September 1997 were included in a prospective study group. These were compared to a retrospective control group of 168 elective general and ENT surgical patients who had been admitted for surgery during May to July 1996.

Patient demographics were similar for both groups. There were also similar proportions of each surgical subtype and degrees of surgical complexity in each group. There were significant reductions in most types of investigations (electrocardiogram, chest X-ray, liver function tests, urea and electrolytes, full blood examination, coagulation profile) ordered with the Day of Surgery Admissions clinic intervention. This resulted in an estimated reduction of preoperative investigation costs by 38%. It was concluded that the clinic intervention was associated with a reduction in indiscriminate preoperative investigation ordering patterns.
Anaesthesia and Postoperative Pain Management for Bilateral Lung Volume Reduction Surgery
Authors: Buettner A. U. , McRae R. , Myles P. S. , Snell G. I. , Bujor M. A. , Silvers A. , Weeks A. M.
Published: January 2019

Bilateral lung volume reduction surgery was introduced into Australia in 1995 for treatment of selected patients with emphysema. We present our experience of the anaesthetic management of our first 55 cases and describe factors associated with outcome. There were four postoperative deaths (7%). Mean (SD) total operation time was 231 (72) minutes. Median intensive care unit (ICU) stay was 26 hours. There was a significant improvement in postoperative lung function (FEV1, VC, 6-minute walk test, all P<0.001). Eight patients (15%) required reintubation for respiratory failure; three of these patients subsequently died. With multivariate analysis, total operation time was the only significant predictor of length of ICU stay R2=0.25, P=0.001), which itself was the only significant predictor of hospital stay duration (R2=0.36, P<0.001).
Supplementary Oxygen and the Laryngeal Mask Airway—Evaluation of a Heat-and-Moisture Exchanger
Authors: Orme R. M. L'E. , Williams M.
Published: January 2019

Heat-and-moisture exchangers (HMEs) are routinely used in anaesthesia for the humidification and warming of inspired gases. The use of the Laryngeal Mask Airway (LMA) is widespread, and many anaesthetists choose to leave it in situ until the patient regains consciousness. In this study, we have investigated the effectiveness of an HME as a means of administering supplemental oxygen via LMA in the immediate postoperative period. Oxygen was administered at varying flow rates via the gas sampling port of the HME and the oxygen delivery recorded, using end-tidal oxygraphy as a measure of alveolar Po2. At an oxygen flow rate of 4 l.min−1, the HME provided a mean end-tidal oxygen concentration of 36.2% (±6.2), which compares favourably to other previously described devices. The HME thus represents a convenient, effective and economical means of oxygen supplementation via the LMA.
The Effect of Devices Used to Reduce the Risk of Blood Spillage or Needlestick Injury on the Flow of Intravenous Infusion Systems
Authors: Jones C. P. , Buchanan G. R.
Published: January 2019

We evaluated the effect of two devices used to reduce needlestick injury and blood spillage on the flow of saline, polygeline and blood through intravenous infusion equipment and their effects on methods of increasing flow. The devices studied all reduced flow compared with control. The reductions were less for the reflux valve (9%) and greater for the anaesthesia extension set (59%), with little further reduction in flow when both were used in series (60%). Reductions in flow increased with increasing viscosity of the fluid infused, being greatest with blood.

The flow reduction produced by the reflux valve was more than compensated by increasing pressure or increasing to the next larger cannula size. The flow reduction produced by the anaesthesia extension was compensated by increasing pressure but not by increasing cannula size.
Estimating the Cost and Utility of Statewide Travel Models using Scenario-Based Interviews
Authors: Francis Daniel , Tsang Flavia , Erhardt Gregory D.
Published: January 2019

Statewide travel models are analysis tools that simulate transportation system conditions and are used to answer “what if” questions about proposed plans and policies. In the United States, they are in use or in development in 39 out of 50 state departments of transportation (DOTs). States without a statewide model are faced with the decision of whether to invest in one, whereas states with models need to decide when and whether to upgrade. Prior efforts to aid this decision making provided detailed synthesis on the cost of statewide modeling, but it has been difficult for other states to use the lessons learned, because cost is largely driven by each state’s specific circumstances. There has also been very little research on quantifying the value of models. To address these gaps, the present research uses a novel scenario-based interview approach. Representatives from 29 DOTs and five consultancies participated in our scenario-based interviews, from which we collected cost estimates for three archetypical statewide models and willingness-to-pay estimates (i.e., perceived value) under nine model development and policy focus scenarios. Our results show that cost ranges from $500,000 for an archetypical Basic 3-Step Model to between $2.8 million and $5 million for an Activity-Based Model for a large state, with data collection comprising a large portion of the cost (36–66%). Further, the perceived value of statewide models exceeds the costs by a factor of 2.4–11.3, with the cost–benefit ratio being higher when a DOT is interested in a broader set of policy issues.
Risk Factors for Lateral Meniscus Posterior Root Tears in the Anterior Cruciate Ligament–Injured Knee: An Epidemiological Analysis of 3956 Patients From the SANTI Study Group
Authors: Praz Cesar , Vieira Thais Dutra , Saithna Adnan , Rosentiel Nikolaus , Kandhari Vikram , Nogueira Helder , Sonnery-Cottet Bertrand
Published: January 2019

Background:

Lateral meniscus posterior root tears (LMPRTs) result in loss of hoop forces and significant increases in tibiofemoral contact pressures. Preoperative imaging lacks reliability; therefore, holding an appropriate index of suspicion, based on the epidemiology of and risk factors for LMPRT, may reduce the rate of missed diagnoses.

Purpose:

The primary objectives of this study were to evaluate the incidence of and risk factors for lateral meniscus root lesions in a large series of patients undergoing anterior cruciate ligament (ACL) reconstruction.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

All patients who underwent primary or revision ACL reconstruction by a single surgeon between January 2011 and April 2018 were considered for study eligibility. From this overall population, all patients who underwent repair of an LMPRT were identified. The epidemiology of LMPRT was defined by the incidence within the study population, stratified by key demographic parameters. Potentially important risk factors for the presence of LMPRT were evaluated in multivariate logistic regression analysis.

Results:

A total of 3956 patients undergoing ACL reconstruction were included in the study. An LMPRT was identified and repaired in 262 patients (6.6%). Multivariate analyses demonstrated that significant risk factors for LMPRT included a contact sports injury mechanism (7.8% incidence with contact sport mechanism vs 4.5% with noncontact mechanism; odds ratio, 1.69; 95% CI, 1.266-2.285; P < .001) and the presence of a medial meniscal tear (7.9% incidence with medial meniscal tear vs 5.8% without; odds ratio, 1.532; 95% CI, 1.185-1.979; P < .001). Although the incidence of LMPRT in male patients (7.3%) was higher than in females (4.8%), this was not significant in multivariate analysis ( P = .270). Patient age, revision ACL reconstruction, and a preoperative side-to-side laxity difference ≥6 mm were not significant risk factors for LMPRT.

Conclusion:

The incidence of LMPRT was 6.6% in a large series of patients undergoing ACL reconstruction. Participation in contact sports and the presence of a concomitant medial meniscal tear were demonstrated to be important independent risk factors. Their presence should raise the index of suspicion for this injury pattern.
Return to Sport and Reoperation Rates in Patients Under the Age of 20 After Primary Anterior Cruciate Ligament Reconstruction: Risk Profile Comparing 3 Patient Groups Predicated Upon Skeletal Age
Authors: Cordasco Frank A. , Black Sheena R. , Price Meghan , Wixted Colleen , Heller Michael , Asaro Lori Ann , Nguyen Joseph , Green Daniel W.
Published: January 2019

Background:

With sports specialization and level of competition on the rise, anterior cruciate ligament reconstruction (ACLR) in athletes under the age of 20 has increased significantly in recent years. Reports have demonstrated that the revision ACLR rate is higher and return to sport (RTS) rate is lower in this population.

Purpose:

To evaluate the 2-year clinical outcomes of 3 cohorts of primary ACLR in pediatric and adolescent athletes under the age of 20 based on skeletal age with a focus on RTS and the incidence of second surgery.

Study Design:

Case series; Level of evidence, 4.

Methods:

This is a prospective evaluation of 324 athletes younger than 20 years of age who underwent ACLR with minimum 2-year follow-up. The surgical technique was selected predicated on skeletal age, which includes the all-epiphyseal technique with hamstring autograft in the youngest cohort in elementary and middle school (group 1), the partial transphyseal and complete transphyseal with hamstring autograft performed for athletes in the middle cohort (group 2), and bone-tendon-bone autograft in the skeletally mature high school athletes (group 3).

Results:

The mean chronological age of the entire cohort was 15 years (range, 8-19 years) with 55% males. The 3 cohorts included 49 patients (15%) in group 1 (mean age, 12 years), 66 (20%) in group 2 (mean age, 14.3 years), and 209 (65%) in group 3 (mean age, 16.2 years). Group 2 athletes had a significantly higher revision ACLR rate (20%) compared with group 1 (6%; P = .039) and group 3 (6%; P = .001). Similarly, group 2 athletes had significantly lower RTS rates (85%) compared with group 1 (100%) and group 3 (94%).

Conclusion:

The rate of revision ACLR was significantly higher and the RTS rates significantly lower in group 2 compared with groups 1 and 3. This age-related risk profile may be used to counsel athletes and parents preoperatively regarding the expectations of surgery with respect to revision ACLR and RTS rates.
Expectations for Return to Preinjury Sport Before and After Anterior Cruciate Ligament Reconstruction
Authors: Webster Kate E. , Feller Julian A.
Published: January 2019

Background:

There is limited information about patient expectations regarding return to sport after anterior cruciate ligament reconstruction (ACLR). While it has generally been assumed that patients expect to return, it has also been acknowledged that expectations may change after surgery.

Purpose:

To investigate return-to-sport expectations before and after ACLR and determine factors associated with changed expectations.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

The study sample consisted of 675 eligible patients (437 male, 238 female). Return-to-sport expectations were recorded preoperatively. Primary ACLR was performed in 595 patients (of whom 81 had a prior contralateral ACLR) and revision ACLR in 80 patients. At 12 months after surgery, the return to preinjury sport status was assessed along with patients’ current sport expectations. The proportion of patients who expected to return to their preinjury level of sport was determined along with actual return rates. Logistic regression was performed to determine the factors associated with the decision to cease sport participation in patients who had expected to be able to return to their preinjury level of sport.

Results:

Overall, 84% of patients expected to be able to return to their preinjury level of sport. Expectations were higher for patients about to undergo their first ACLR, with 88% expecting to return, than for those about to undergo revision surgery or second primary ACLR (63% and 80% expected to return, respectively; P < .001 and P = .08, respectively). At 12 months after surgery, 24% of patients who expected to return to their preinjury level of sport had actually returned, and 15% of all patients had already decided to give up sport. In the regression models, being female ( P = .02) and having undergone previous ACLR ( P < .0001) were factors significantly associated with the decision to give up sport participation.

Conclusion:

Patients had high expectations for returning to their preinjury level of sport at the time of undergoing initial ACLR. Expectations were lower for those who had undergone previous ACLR. Female patients and patients who had undergone previous ACLR were more likely to change their expectations and cease sport participation. These data can be used to provide patients with realistic return-to-sport expectations in the first postoperative year and highlight the challenge for patients who aim to return from multiple ACL injuries.
An Investigation of Concurrent Validity of Fidelity of Implementation Measures at Initial Years of Implementation
Authors: Khoury Caitlin Rasplica , McIntosh Kent , Hoselton Robert
Published: January 2019

Fidelity of implementation of school practices is crucial to student outcomes. Several types of tools, including self-assessments, are available for measuring fidelity, but little is known regarding the relation of self-assessments of fidelity to fidelity instruments completed with the support of external experts, specifically, during the first few years of implementation. The present study used cross-sectional data from 1,438 schools to examine relations between fidelity self-assessment and team-based fidelity measures in the first 4 years of implementation of School-Wide Positive Behavioral Interventions and Supports (SWPBIS). Results showed strong positive correlations between fidelity self-assessments and a team-based measure of fidelity at each year of implementation.
Advances in Measurement in School-Wide Positive Behavioral Interventions and Supports
Authors: McIntosh Kent , Lane Kathleen Lynne
Published: January 2019

In recent years, there has been an increased research focus on developing tools to support the design, installation, and evaluation of tiered systems of support. In this special issue, we focus on research validating freely available tools to (a) measure fidelity of implementation of school-wide positive behavioral interventions and supports (SWPBIS), (b) assess staff commitment to implement SWPBIS, (c) inform development of teaching matrices, (d) examine issues of sustainability, and (e) assess school climate.
Fault diagnosis based on the quality effect of learning algorithm for manufacturing systems
Authors: Djelloul Imene , Sari Zaki , Sidibe Ibrahima dit Bouran
Published: January 2019

Fault diagnosis is becoming an important issue in industrial environment, and the accurate diagnosis is the most significant part in fault handling. This article discusses a fault detection and diagnosis problem for manufacturing systems taking into account rapid detection and speed performances of fault isolation with minimum ambiguity. However, in many complex real plants, it may not be possible to discover accurately the causes of probable faults. The accuracy of fault or fault detection by the traditional approaches is not adequate. Considering the quality effect of the learning algorithm, a new hybrid neural network approach is developed using the integration of a regression task for classification accuracy. Two models of neural networks: gradient descent and momentum & adaptive learning rate and Levenberg–Marquardt are investigated and compared. The performance of the proposed approach is evaluated using mean square error, convergence speed, and classification accuracy. The case study and experimental results are presented and discussed. A comparison with the Levenberg–Marquardt regression approach shows the importance of considering the proposed learning algorithm quality in the fault detection and diagnosis problem compared with those reported in the literature.
Multivariate and machine learning approaches for honey botanical origin authentication using near infrared spectroscopy
Authors: Bisutti Vittoria , Merlanti Roberta , Serva Lorenzo , Lucatello Lorena , Mirisola Massimo , Balzan Stefania , Tenti Sandro , Fontana Federico , Trevisan Giulia , Montanucci Ludovica , Contiero Barbara , Segato Severino , Capolongo Francesca
Published: January 2019

In this work the feasibility of near infrared spectroscopy was evaluated combined with chemometric approaches, as a tool for the botanical origin prediction of 119 honey samples. Four varieties related to polyfloral, acacia, chestnut, and linden were first characterized by their physical–chemical parameters and then analyzed in triplicate using a near infrared spectrophotometer equipped with an optical path gold reflector. Three different classifiers were built on distinct multivariate and machine learning approaches for honey botanical classification. A partial least squares discriminant analysis was used as a first approach to build a predictive model for honey classification. Spectra pretreatments named autoscale, standard normal variate, detrending, first derivative, and smoothing were applied for the reduction of scattering related to the presence of particle size, like glucose crystals. The values of the descriptive statistics of the partial least squares discriminant analysis model allowed a sufficient floral group prediction for the acacia and polyfloral honeys but not in the cases of chestnut and linden. The second classifier, based on a support vector machine, allowed a better classification of acacia and polyfloral and also achieved the classification of chestnut. The linden samples instead remained unclassified. A further investigation, aimed to improve the botanical discrimination, exploited a feature selection algorithm named Boruta, which assigned a pool of 39 informative averaged near infrared spectral variables on which a canonical discriminant analysis was assessed. The canonical discriminant analysis accounted a better separation of samples according to the botanical origin than the partial least squares discriminant analysis. The approach used has permitted to achieve a complete authentication of the acacia honeys but not a precise segregation of polyfloral ones. The comparison between the variables important in projection and the Boruta pool showed that the informative wavelengths are partially shared especially in the middle and far band of the near infrared spectral range.