bluuebunny/crossref_metadata_2025 huggingface dataset:
Perioperative Fluid Prescription, Complications and Outcomes in Major Elective Open Gastrointestinal Surgery
Authors: Warrillow S. J. , Weinberg L. , Parker F. , Calzavacca P. , Licari E. , Aly A. , Bagshaw S. , Christophi C. , Bellomo R.
Published: January 2019

Perioperative fluid therapy and associated outcomes of patients undergoing major elective open gastrointestinal surgery are poorly understood. This study measured perioperative fluid therapy, complication rates and outcomes for major elective open gastrointestinal surgery in a tertiary care hospital. We obtained demographic data, operative details, fluid prescription, complications and outcomes in 100 patients. Patients were elderly and had multiple comorbidities. Median delivered intraoperative fluid volume was 4.2 litres, followed by 6.3 litres over the subsequent 24 hours. Perioperative fluid prescription was associated with a positive fluid balance. Complications occurred in 57% of patients with 32% experiencing at least one major complication. Serious complications were substantially more frequent in patients having non-colorectal operations. The most common adverse events were pulmonary oedema (21%), ileus (18%), serious sepsis (17%), pneumonia (17%), arrhythmias (14%), delirium (14%) and wound healing problems (infections 13%, anastomotic leaks 12%). Mortality at 30 days was 2%. This study provides planning data for future interventional studies.
International Albumin Use: 1995 to 2006
Authors: Jones D. , Mcevoy S. , Merz T. M. , Higgins A. , Bellomo R. , Cooper J. D. , Hollis S. , McArthur C. , Myburgh J. A. , Taylor C. , Liu B. , Norton R. , Finfer S.
Published: January 2019

Over the last ten years more reliable information regarding the risks and benefits of the use of albumin for fluid resuscitation has emerged. To determine what influence this has had on clinical practice, we sought to document albumin use (from mass of albumin supplied to hospitals) in 16 industrialised countries between 1995 and 2006. Data on national albumin and synthetic colloid use was sought from independent intensive care researchers and albumin issuers. The mass of albumin supplied per 10,000 persons on an annual basis by country and aggregated across the study countries was calculated. Volumes of synthetic colloid supplied per 10,000 persons were calculated. Data were obtained for 15 countries. Albumin use varied significantly between countries and throughout the observation period. Overall, aggregate albumin use decreased from a peak of 2.54 kg per 10,000 persons in 1995 to 1.40 kg per 10,000 persons in 1999; use has remained relatively constant since. Data on supply of synthetic colloids was available in only three countries and varied from 11.7 litres per 10,000 persons in Canada in 1995, to 231.8 litres per 10,000 persons in Denmark in 2004. Between 1995 and 1999 albumin use decreased and has been materially constant since; where data were available, use of synthetic colloids increased. Whether these practice changes have resulted in a net health gain or in harm requires further research.
A Randomised Controlled Trial of Hyperbaric Bupivacaine with Opioids, Injected as Either a Mixture or Sequentially, for Spinal Anaesthesia for Caesarean Section
Authors: Desai S. , Lim Y. , Tan C. H. , Sia A. T. H.
Published: January 2019

It is common practice to mix opioids with hyperbaric bupivacaine in a single syringe before intrathecal injection of the mixture. Mixing these drugs may alter the density of the hyperbaric solution, affecting the spread of local anaesthetic and opioid. Forty-eight women having elective caesarean section under spinal anaesthesia were recruited to this double-blind, randomised trial. Group M (n=24) received 2 ml of 0.5% hyperbaric bupivacaine plus morphine 100 μg plus fentanyl 15 μg, mixed in a syringe prior to administration. Group S (n=24) received 2 ml of 0.5% bupivacaine through one syringe, followed by morphine 100 μg plus fentanyl 15 μg through a separate syringe. All patients received patient-controlled intravenous morphine for 24 hours postoperatively. Block characteristics, postoperative pain scores and morphine use were noted. The patients in Group M had higher levels of sensory block to cold than those in Group S (median T2 vs T3)(P=0.003). Five patients in Group M and none in Group S had a block to cold ≥T1 (P=0.02). There was no difference between groups in the incidence of hypotension, need for vasopressor or side-effects. Morphine consumption was significantly higher in group M (13.3±11.2 vs 6.2±7.2 mg, P=0.015). Mixing of fentanyl and morphine with hyperbaric bupivacaine results in a higher level of sensory block than sequential administration of bupivacaine then opioid and may be associated with higher postoperative opioid requirement.
Prognostic Factors in Critically Ill Patients with Solid Tumours Admitted to an Oncological Intensive Care Unit
Authors: Ñamendys-Silva S. A. , Texcocano-Becerra J. , Herrera-Gómez A.
Published: January 2019

The mortality and prognostic factors for patients admitted to the intensive care unit (ICU) with solid tumours are unclear. The aim of this study was to describe demographic, clinical and survival data and to identify factors associated with mortality in critically ill patients with solid tumours. A prospective observational cohort study of 177 critically ill patients with solid tumours admitted to a medical-surgical oncological ICU was undertaken. There were no interventions. Among the admissions, 66% were surgical, 79.7% required mechanical ventilation during their stay in the ICU and 31.6% presented with severe sepsis or septic shock. In a multivariate analysis, independent prognostic factors for in-ICU death were the need for vasopressors (OR: 22.66, 95% confidence interval: 6.09 to 82.22, P <0.001) and the acute physiology and chronic health evaluation (APACHE) II score (OR: 1.92, 95% confidence interval: 1.43 to 2.58, P <0.001). Cox multivariate analysis identified the length of stay in the ICU, Charlson comorbidity index score greater than 2, and the need for vasopressors as independent predictors of death after ICU discharge. The mortality rate in the ICU was 21.4%. Improved outcomes in critically ill cancer patients extended to the subgroup of patients with solid tumours. Independent prognostic factors for in-ICU death were the need for vasopressors and the APACHE II score, while the length of stay in the ICU, Charlson comorbidity index score >2, and the need for vasopressors were independent predictors of death after ICU discharge.
Patients’ Understanding of Technical Terms used during the Pre-Anaesthetic Consultation
Authors: Babitu U. Q. , Cyna A. M.
Published: January 2019

Communication between patients and anaesthetists is being recognised as an increasingly important aspect of clinical care. Patients need to understand the nature and consequences of any proposed procedure prior to giving informed consent. In this regard, anaesthetists have a responsibility to provide adequate information about anaesthesia and related procedures in a form that patients are likely to understand. We investigated whether patients understood the technical terms used by the anaesthetist. We observed 68 obstetric and gynaecological pre-anaesthesia consultations at two tertiary hospitals in South Australia. These pre-anaesthesia consultations were conducted by consultant anaesthetists on 46 occasions (68%) and by anaesthesia trainees (nine registrars and one resident medical officer) on 22 occasions (32%). Approximately half of the patients participating in the study (45%) failed to understand one or more of the terms used during their consultation. Of the technical terms used more than once, “reflux” was the most poorly understood, with seven of 36 patients (19%) having either poor or no understanding. The next five most commonly misunderstood technical terms were “aspiration”, “allergy”, “anaphylaxis, “local anaesthetic” and “sedation”. We have identified many technical terms that may not be understood by patients presenting for anaesthesia care. An awareness of commonly misunderstood words may facilitate better transfer of information during pre-anaesthesia consultations. Our study findings should remind doctors that patients frequently fail to understand or take in what we tell them.
Lupus Anticoagulant, Antiphospholipid Syndrome and Cardiac Surgery
Authors: Cartwright B. L. , Bean M. , Cooper J. O.
Published: January 2019

The presence of lupus anticoagulant and the related condition antiphospholipid syndrome present a challenge in cardiac surgery where measured anticoagulation may not reflect the in vivo patient status of hypercoagulation. We report the successful management of a patient with lupus anticoagulant presenting for aortic valve replacement and coronary revascularisation. We used heparin for anticoagulation, specialised additional tests of anticoagulation and a reduced protamine dose. We also used tranexamic acid. The clinical problems with anticoagulation in patients with lupus anticoagulant include anticoagulant choice, measurement of adequate anticoagulation, antifibrinolytic usage, protamine dosing and blood product transfusion.
High Output Cardiac Failure in a Parturient with Hereditary Haemorrhagic Telangiectasia
Authors: Lai C. F. , Dennis A. , Graham J.
Published: January 2019

Hereditary haemorrhagic telangiectasia is a genetic condition which results in arteriovenous malformations involving the skin, mucous membranes, lung, brain, gastrointestinal tract, liver and spinal canal. The shunting of blood through arteriovenous malformations, especially in the liver, leads to maldistribution of cardiac output. In order to supply blood to vital organs, cardiac output is increased through vasodilation, elevated stroke volume and elevated heart rate. Pregnancy can worsen the effects of the arteriovenous malformations. We present the peripartum management of a woman with hereditary haemorrhagic telangiectasia predominantly involving the liver that resulted in high output cardiac failure during two consecutive pregnancies.
CPAP of 10 cmH2O during Cardiopulmonary Bypass followed by an Alveolar Recruitment Manoeuvre Does not Improve Post-Bypass Oxygenation Compared to a Recruitment Manoeuvre Alone in Children
Authors: Kim J. T. , Na H. S. , Kim H. S. , Kim C. S. , Kim S. D.
Published: January 2019

This randomised controlled study assessed whether continuous positive airway pressure (CPAP) of 10 cmH2O during cardiopulmonary bypass improves post-bypass oxygenation in children compared with no CPAP during bypass. We studied children with a ventricular septal defect. CPAP of 10 cmH2O was applied during bypass in the CPAP group (n=24), whereas the lungs were left deflated in the control group (n=20). In both groups, an alveolar recruitment maneouvre was performed by applying positive pressure of 30 to 40 cmH2O for five seconds before weaning from bypass. Postoperative ventilation had the peak inflation pressure set to produce an expired tidal volume of 8 ml/kg with positive end expiratory pressure of 5 cmH2O. Arterial blood gas and haemodynamic measurements were performed at skin incision, five minutes after weaning from bypass, five minutes after chest closure and four hours after arrival in the intensive care unit. In four children CPAP was discontinued because it adversely affected the operating field. There was no difference in demographic characteristics, haemodynamic data, bypass time and operation time. No difference was observed between the groups with respect to pH, PaO2, P(A-a) DO2, PaCO2, and ETCO2 at each time. Variability in the data was greater than expected, leading to a decrease in the expected power of the study. CPAP at 10 cmH2O during bypass was not found to improve the post-bypass oxygenation as compared with leaving the lung deflated during bypass in children undergoing ventricular septal defect repair who had an alveolar recruitment maneouvre at the end of bypass.
Effects of Skin Traction on Cross-Sectional Area of the Internal Jugular Vein in Infants and Young Children
Authors: Suk E. H. , Kim D. H. , Kil H. K. , Kweon T. D.
Published: January 2019

Internal jugular veins (IJV) are commonly used to obtain central venous access. However, percutaneous cannulation of the IJV is difficult in infants and young children because of its diminutive size. The aim of this study was to evaluate the effect of skin traction on the cross-sectional area of the IJV in anaesthetised infants (younger than one year) and young children (one to six years) using ultrasound. Sixty-seven subjects undergoing general anaesthesia were studied. The cross-sectional area of the IJV was measured at the junction of the two heads of the sternocleidomastoid using ultrasound. Skin traction was performed by stretching the skin over the puncture point with pieces of surgical tape in both cephalad and caudad directions. The measurements were made after the induction of anaesthesia with patients in the supine position and with positive pressure ventilation. Skin traction increased the maximum cross-sectional area of the IJV by 39.9∓29.6% in infants and by 33.8∓21.9% in children (P <0.01). This increase might facilitate easier and safer IJV cannulation in infants and children.
Pharmacoeconomics of Volatile Inhalational Anaesthetic Agents: An 11-Year Retrospective Analysis
Authors: Weinberg L. , Story D. , Nam J. , McNicol L.
Published: January 2019

With continuously increasing expenditure on health care resources, various cost containment strategies have been suggested in regard to controlling the cost of inhalational anaesthetic agents. We performed a cost identification analysis assessing inhalational anaesthetic agent expenditure at a tertiary level hospital, along with an evaluation of strategies to contain the cost of these agents.

The number of bottles of isoflurane, sevoflurane and desflurane used during the financial years 1997 to 2007 was retrospectively determined and the acquisition costs and cumulative drug expenditure calculated. Pharmacoeconomic modelling using low fresh gas flow anaesthesia was performed to evaluate practical methods of cost reduction.

The use of isoflurane decreased from 384 bottles during 1997 to 204 in 2007. In contrast, use of sevoflurane increased from 226 bottles during 1998 to 875 during 2007. Desflurane use increased from 34 bottles per year during 2002 (its year of introduction) to 163 bottles per year in 2007. While the inflation-adjusted cumulative expenditure for these inhalational agents (Australian dollars) increased from $132,000 in 1997 to over $326,000 in 2007, an increase of 168%, patient workload over the same period increased by only 11%. Pharmacoeconomic modelling demonstrated that sevoflurane at 2 l/minute costs 19 times more than isoflurane at 0.5 l/minute.

For the financial years 1997 to 2007, we found a progressive shift from the cheaper isoflurane to the more expensive agents, sevoflurane and desflurane, a shift associated with marked increases in costs. Low flow anaesthesia with isoflurane is one strategy to reduce costs.
Risk Factors and Outcomes of High-Dependency Patients Requiring Intensive Care Unit Admission: A Nested Case-Control Study
Authors: Gould A. , Ho K. M. , Dobb G.
Published: January 2019

Intermediate-care or high-dependency units can provide a level of care that lies between the intensive care unit (ICU) and general ward, but the patients who are most likely to benefit from such level of care remains uncertain. This nested case-control study assessed the incidence and risk factors of high-dependency patients requiring ICU admission and whether these admissions were associated with a worse outcome when compared to other emergency ICU admissions. Seventy-seven consecutive high-dependency patients requiring ICU admission (cases) were compared with 77 patients who did not require ICU admission (controls) and also 928 emergency ICU admissions from other areas. The incidence of high-dependency patients requiring ICU admission was 6.7% (95% confidence interval 5.3 to 8.2). High-dependency admissions from the ward (odds ratio 4.46, 95% confidence interval 1.55 to 12.78) or emergency department (odds ratio 4.48, 95% confidence interval 1.54 to 13.0) and a need for concurrent non-invasive ventilation, inotrope infusion and acute kidney injury (odds ratio 14.90, 95% confidence interval 3.79 to 58.3) was associated with a higher risk of ICU admission. Hospital mortality of the high-dependency patients requiring ICU admission was not significantly different from other emergency ICU admissions (odds ratio 1.08, 95% confidence interval 0.55 to 2.11). In summary, high-dependency patients requiring ICU admission were uncommon unless they had multi-organ failure and their hospital mortality was not significantly different from other emergency ICU admissions.
Continuous Central Venous Oxygen Saturation Monitoring under Varying Physiological Conditions in an Animal Model
Authors: Kissoon N. , Spenceley N. , Krahn G. , Milner R.
Published: January 2019

We compared saturations from a paediatric central venous oximetry catheter with co-oximetry values with changes in drug infusions, intravascular blood volume and hypoxia in an animal model. Piglets (large white) were anaesthetised, intubated and mechanically ventilated. PediaSat® oximetry catheters were placed in the superior vena cava via jugular vein cut-down and in the inferior vena cava percutaneously via the femoral vein. A carotid arterial catheter was placed via cut-down for blood sampling and pressure monitoring. Anaesthesia was maintained with continuous thiopentone and supplemental morphine. Haemodynamics (heart rate, mean arterial blood, central venous pressure), fibreoptic ScvO2 (ScvO2-inferior) from inferior vena cava, fibreoptic ScvO2 (ScvO2-superior) from superior vena cava and blood gas oximetry (ScvO2-co-ox) were measured simultaneously at predetermined intervals during increasing adrenaline and sodium nitroprusside infusions and during increasing hypoxia and hypovolaemia. There was good agreement of both superior vena cava and inferior vena cava ScvO2 catheters with co-oximetry during adrenaline and sodium nitroprusside infusions. During the hypoxia study there was good agreement between the co-oximeter to ScvO2-superior catheter, but poor agreement with to the inferior vena cava catheter samples. In the hypovolaemic phase of the experiment there was good agreement between the measured co-oximetry value and ScvO2-superior catheter until the mean blood pressure reached 43 mmHg. The oximetry catheter is capable of identifying changes in ScvO2 under physiological conditions usually encountered in clinical medicine but was less accurate at the extremes of physiology and when placed in the inferior vena cava catheter especially during hypovolaemia and hypoxia.
A Comparison of Two Different Doses of Rectal Ketamine Added to 0.5 mg.kg-1 Midazolam and 0.02 mg.kg-1 Atropine in Infants and Young Children
Authors: Wang X. , Zhou Z. J. , Zhang X. F. , Zheng S.
Published: January 2019

In some circumstances, a high degree of sedation that results in a child being unconscious at the time of parental separation is desirable. We set out to investigate the efficacy and safety of a rectal premedication regimen designed to produce this increased level of sedation.

Sixty-seven children aged two to 24 months were randomised into two groups. Group MK received 4 mg.kg-1 ketamine, 0.5 mg.kg-1 midazolam and 0.02 mg.kg-1 atropine and group MKK received 8 mg.kg-1 ketamine, 0.5 mg.kg-1 midazolam and 0.02 mg.kg-1 atropine per rectum. The sedation score at the time of parental separation 30 minutes after drug administration and the response to intravenous cannulation were evaluated on a four-point scale. Respiratory rate, heart rate and arterial oxygen saturation were recorded immediately before parental separation.

More patients in group MKK were asleep during separation (62 vs 35%, P <0.05). Fewer patients in group MKK cried during intravenous cannulation (37 vs 68%, P <0.05). Sedation scores were significantly increased at both time points. There was no difference between groups in vital signs at the time of parental separation and no adverse respiratory events occurred during the study period.

In cases where a high degree of sedation following premedication in infants and toddlers is desired, the addition of 8 mg.kg-1 ketamine to 0.5 mg.kg-1 midazolam and 0.02 mg.kg-1 atropine administered rectally is more efficacious than 4 mg.kg-1 ketamine.
The Provision of Anaesthesia for Children by Non-Subspecialist Anaesthetists: Expectations of Newly Qualified Consultant Anaesthetists and their Prospective Employers in Victoria
Authors: Castanelli D. J. , Stevenson K. , Monagle J. P.
Published: January 2019

We surveyed newly qualified consultant anaesthetists and their prospective employers in Victoria, regarding their expectations for the provision of paediatric anaesthesia by anaesthetists who have not completed subspecialty training in paediatric anaesthesia (generally-trained anaesthetists).

Responses were received from 15 of 19 (79%) eligible Directors and 26 of 37 (70%) newly qualified Australian and New Zealand College of Anaesthetists (ANZCA) Fellows. Of those responding, 80% of Directors and 82% of Fellows would expect a generally-trained anaesthetist to anaesthetise children two years of age or older. Regional Directors expected generally-trained anaesthetists to anaesthetise younger children than metropolitan Directors, and Directors’ expectations were not influenced by their own practice.

Testing these age limits with a series of simple case descriptions showed there is recognition from both Directors and Fellows that the stated age limits would be modified in both directions by case complexity and comorbidities.

The new consultants who responded were significantly less confident than Directors in their ability to resuscitate and stabilise a critically ill child prior to transfer if required. Only 50% agreed they still met all the requirements of the ANZCA paediatric module and only 37.5% had the level of confidence they achieved during their paediatric rotations.

We suggest that current training provides capacity to routinely anaesthetise well children two years of age or older. However, it appears more training would be required for most anaesthetists undertaking anaesthesia for younger patients or more complex paediatric cases. This raises the question of subspecialty endorsements within ANZCA Fellowship.
Prognosis and Resuscitation Status of Critically Ill Patients with Lung Cancer Admitted to the Intensive Care Unit
Authors: Aldawood A. S.
Published: January 2019

The aims of the study were to assess the intensive care unit (ICU) outcome for critically ill patients with lung cancer, to determine the risk factors for mortality and to examine the resuscitation status on admission and during their ICU course. Data was collected from May 1999 to March 2009 for patients with lung cancer admitted to the ICU. During the study period, 51 patients with lung cancer were admitted to our ICU. The ICU and hospital mortality rates were 49 and 60%, respectively. The majority of patients were full resuscitation on admission to ICU. The resuscitation status was changed in 56% of patients during the ICU course. It is suggested that end-of-life decisions should be addressed earlier in these patients’ illnesses.
What are we Telling Our Patients? A Survey of Risk Disclosure for Anaesthesia in Australia and New Zealand
Authors: Braun A. R. , Leslie K. , Merry A. F. , Story D.
Published: January 2019

The aim of our study was to determine the range of risks disclosed in four commonly-encountered clinical scenarios: knee arthroscopy, lumbar laminectomy, laparoscopic appendicectomy and laparotomy, and then to determine how often five commonly-disclosed risks were disclosed for each scenario. We conducted a pilot survey of consultant anaesthetists in the Auckland City Hospital, the Royal Melbourne Hospital and the Austin Hospital (response rate 59%). A web survey was then sent to 500 randomly-selected Australian and New Zealand College of Anaesthetists Fellows (response rate 29%). In the pilot survey, a wide range of risks were disclosed: five (range 0 to 13) for knee arthroscopy, seven (0 to 16) for lumbar laminectomy, six (0 to 13) for appendicectomy and nine (0 to 24) for laparotomy. In the web survey, the disclosure rates for all risks varied widely from “rarely” to “always”. Respondents were more likely to disclose risks infrequently if they were male (odds ratio 5.7, P=0.002) or exclusively in private practice (odds ratio 4.1, P=0.02). Age >45 years was not associated with disclosure frequency (odds ratio 1.65, P=0.23).

While the low response rate limits the validity and generalisability of many of our findings, we can nevertheless confidently conclude that risk disclosure varies widely in Australia and New Zealand. This large variation should be of concern to all anaesthetists. More work is needed to understand the reasons for this variation, and to develop a stronger consensus among anaesthetists about what risks should be disclosed.
Acute Subdural Haematoma in the Presence of an Intrathecal Catheter Placed for the Prevention of Post-Dural Puncture Headache
Authors: Sharma S. , Halliwell R. , Dexter M. , Mudaliar Y. , Yee K.
Published: January 2019

A 31-year-old term primigravid woman had an intrathecal catheter placed following a dural puncture during attempted epidural analgesia during labour. After 23 hours she developed sudden loss of consciousness and an urgent brain computed tomography scan demonstrated a large left hyper-acute subdural haematoma. Craniotomy revealed active bleeding from a ruptured left temporal bridging vein. She was extubated 12 hours after surgery and was discharged home 11 days later without neurological deficit. Although subdural haematoma is a recognised complication of dural puncture, it has not been reported in the presence of an intrathecal catheter. An intrathecal catheter may not always prevent cerebrospinal fluid efflux, so subdural haematoma remains a potential complication of inadvertent dural puncture.
Ultrasound-Guided Bilateral Superior Laryngeal Nerve Block to Aid Awake Endotracheal Intubation in a Patient with Cervical Spine Disease for Emergency Surgery
Authors: Manikandan S. , Neema P. K. , Rathod R. C.
Published: January 2019

Ultrasound has been widely used to locate nerves for various nerve blocks. The potential advantages of using ultrasound imaging for nerve blocks include reduction in the amount of local anaesthetic required, improved success rate, reduced time to perform the block and reduced complication rate. We describe the successful performance of ultrasound-guided bilateral superior laryngeal nerve block to facilitate awake fibreoptic intubation in a patient presenting for emergency surgery on the cervical spine.
Risk Factors for Hospital-Acquired Pneumonia Caused by Imipenem-Resistant Pseudomonas Aeruginosa in an Intensive Care Unit
Authors: Furtado G. H. , Gales A. C. , Perdiz L. B. , Santos A. F. , Wey S. B. , Medeiros E. A.
Published: January 2019

Imipenem-resistant Pseudomonas aeruginosa is a leading cause of hospital-acquired pneumonia. Aiming to determine the risk factors associated for hospital-acquired pneumonia due to imipenem-resistant Pseudomonas aeruginosa, we undertook a retrospective case-case-control study. Patients admitted to a 14-bed medical-surgical intensive care unit from a university-affiliated hospital with hospital-acquired pneumonia caused by imipenem-resistant Pseudomonas aeruginosa strains and by imipenem-susceptible Pseudomonas aeruginosa strains were matched to control patients by time under risk and comorbidities. A total of 58 resistant cases, 47 susceptible cases and 237 controls were evaluated. The risk factors independently associated to hospital-acquired pneumonia caused by imipenem-resistant Pseudomonas aeruginosa were: duration of hospitalisation, Acute Physiological and Chronic Health Evaluation II score, male gender, receipt of haemodialysis, receipt of piperacillin-tazobactam and receipt of third-generation cephalosporins.
Plasma Levels of Lignocaine during Tumescent Local Anaesthesia in Children with Burns
Authors: Bussolin L. , Serio P. , Busoni P. , Schiatti R. , Salvadori M.
Published: January 2019

The aim of the study was to assess the changes in plasma lignocaine concentrations over time when the tumescent solution is injected into subcutaneous tissue of children undergoing surgical treatment of burns. Sixteen consecutive children with burns were studied using a prospective study design. After induction of general anesthesia, tumescent lignocaine solution 0.1% with adrenaline in nine patients (adrenaline group) for the treatment of postburn sequelae, or without adrenaline in seven patients (no-adrenaline group) for the treatment of acute burns, was injected into the subcutaneous tissue of burned and donor areas. The maximum dose of lignocaine was 7 mg/kg. Blood samples were collected before the start of the injection as well as at 5, 10, 20, 30, 45, 60, 90 minutes and 2, 4, 8, 12, 24 hours after the infiltration was completed. The course of lignocaine plasma levels was chaotic in the adrenaline group and biphasic during the first hour in the no-adrenaline group. The maximum plasma concentration of lignocaine was 2.09 μg/ml in the adrenaline group and 1.98 μg/ml in the no-adrenaline group. No adverse reactions were noted. Tumescent injection in burned children resulted in lignocaine plasma concentrations that were always lower than the often quoted value of 5 μg/ml, considered to be the toxic plasma threshold in adults. These data lend support to the use of lignocaine using the tumescent technique in burned paediatric patients.
The use of ProSeal Laryngeal Mask Airway in Caesarean Section - Experience in 3000 Cases
Authors: Halaseh B. K. , Sukkar Z. F. , Hassan L. Haj , Sia A. T. H. , Bushnaq W. A. , Adarbeh H.
Published: January 2019

Rapid sequence induction is currently the recommended technique in general anaesthesia for caesarean section. However, the usefulness of the ProSeal™ laryngeal mask airway as a rescue airway in the event of difficult or failed intubation has been recognised in numerous case reports. In this study, we report the experience of the use of the ProSealTM laryngeal mask in 3000 elective caesarean sections in a single centre, using a method of insertion that allows a rapid establishment of a patent airway together with gastric drainage.
Dapsone-Associated Methaemoglobinaemia in Patients with a Haematologic Malignancy
Authors: Subramaniam A. , Corallo C. , Nagappan R.
Published: January 2019

Methaemoglobinaemia is an uncommon problem which can significantly impact on oxygen carriage and may necessitate intensive care management. The occurrence of symptomatic methaemoglobinaemia over a three-month period in four patients with haematological malignancies on dapsone for Pneumocystis jiroveci pneumonia prophylaxis prompted a review of its use in this group of patients. We performed a retrospective audit to identify any contributing factors. Co-oximetry was employed to identify patients with methaemoglobinaemia. Thirty-four patients with haematological malignancies received dapsone between January and December 2008, of whom 53% (n=18) had co-oximetry studies done. Raised methaemoglobin levels (≥1.5%) were seen in 13 patients, four of them symptomatic. Mean peak level was of 7.84% (range 1.9 to 26.8%). Eight patients required intensive care support. Mean onset of methaemoglobinaemia was 11.8 days (range 4 to 18 days) following dapsone commencement. All patients were anaemic with an average haemoglobin of 85.5 g/l (range 59 to 111 g/l). All patients were prescribed ‘azole’ antifungal agents and five patients were also on high-dose steroids, both agents known to induce cytochrome P-450 enzymes and hence potentiating dapsone toxicity. Our experience suggests that dapsone should be used with caution in patients with haematological malignancies as they are particularly at risk of developing symptomatic methaemoglobinaemia due to underlying anaemia, immunosuppression and potential drug interactions. The current recommendation of dapsone for Pneumocystis jiroveci pneumonia prophylaxis in this group of patients needs to be reviewed. When methaemoglobinaemia does occur, early recognition is possible with routine co-oximetry testing and prompt treatment may lessen the need for or duration of intensive care supports.
The Portable Glostavent®: A New Anaesthetic Machine for use in Difficult Situations
Authors: Tully R. , Eltringham R. , Walker I. A. , Bartlett A. J.
Published: January 2019

A portable version of the Glostavent® anaesthetic machine is described in which recent developments in draw-over technology are incorporated into a traditional draw-over anaesthetic system. The additional features include a more efficient reservoir and an improved vaporiser, which have enhanced the performance and versatility. The portable Glostavent weighs less than 10 kg and is transported in a container the size of a small suitcase. It can be used to provide inhalational anaesthesia safely and economically in situations where there are no support facilities. It is ideal for use in battlefield or disaster situations and in isolated hospitals in disadvantaged regions of the world.
Epidural Volume Extension: A Review
Authors: Tyagi A. , Sharma C. S. , Kumar S. , Sharma D. K. , Jain A. K. , Sethi A. K.
Published: January 2019

Epidural volume extension is a technical modification of the combined spinal epidural block. It involves the epidural injection of normal saline or a small volume of local anaesthetic after an intrathecal injection, aiming to augment the post-spinal sensory level. Although the consequent sensory block augmentation has been adequately documented, the probable factors influencing epidural volume extension and its implications for clinical practice are not well defined. This article reviews published literature relating to the probable factors affecting epidural volume extension, its clinical implications, case reports of its successful clinical application and summarises its unexplored effects.
Anaesthesia for Robotic Gynaecological Surgery
Authors: Gupta K. , Mehta Y. , Jolly A. Sarin , Khanna S.
Published: January 2019

Robotic surgery is gaining widespread popularity due to advantages such as reduced blood loss, reduced postoperative pain, shorter hospital stay and better visualisation of fine structures. Robots are being used in urological, cardiac, thoracic, orthopaedic, gynaecological and general surgery. Robotic surgery received US Food and Drug Administration approval for use in gynaecological surgery in 2005.

The various gynaecological robotic operations being performed are myomectomy, total and supracervical hysterectomy, ovarian cystectomy, sacral colpopexy, tubal reanastomosis, lymph node dissection, surgery of retroperitoneal ectopic pregnancy, Moskowitz procedure and endometriosis surgery.

The anaesthetic considerations include difficult access to the patient intraoperatively, steep Trendelenburg position, long surgical duration and the impact of pneumoperitoneum. We highlight the complications encountered in these surgeries and methods to prevent these complications.

Robotic gynaecological surgery can be safely performed after considering the physiological effects of the steep Trendelenburg position and of pneumoperitoneum. The benefits of the surgical procedure should be weighed against the risks in patients with underlying cardiorespiratory problems.
Observations on the Assessment and Optimal Use of Videolaryngoscopes
Authors: Greenland K. B. , Segal R. , Acott C. , Edwards M. J. , Teoh W. H. L. , Bradley W. P. L.
Published: January 2019

Due to the large number of videolaryngoscopes now available, it might be difficult for novice users to assess the various devices or use them optimally. We have collated the experiences of several airway management experts to assist in the assessment and optimal use of seven commonly used videolaryngoscopes. While all videolaryngoscopes have unique features, they can be broadly divided into those inserted via a midline approach over the tongue and those inserted laterally along the floor of the mouth. Videolaryngoscopes that are placed on the floor of the mouth displace the tongue antero-laterally and flatten the submandibular tissues. They generally require a conventional shaped bougie for tracheal intubation. Videolaryngoscopes that use the midline approach may have an in-built airway conduit for the tracheal tube or may require a ‘J-shaped’ stylet in the tracheal tube to negotiate the upper airway. This may cause difficulty when the tracheal tube is inserted through the glottis and the tip abuts the anterior wall of the subglottic space. Knowledge of the mechanism used by videolaryngoscopes to achieve laryngoscopy is essential for safe and successful tracheal intubation when using these devices.
A Comparison of Pulse Contour Wave Analysis and Ultrasonic Cardiac Output Monitoring in the Critically Ill
Authors: Udy A. A. , Altukroni M. , Jarrett P. , Roberts J. A. , Lipman J.
Published: January 2019

Cardiac output (CO) is a key determinant of major organ blood flow and solute delivery to drug eliminating organs. As such, CO assessment is a key covariate in understanding altered drug handling in the critically ill. Newer minimally-invasive devices are providing unique platforms for such an application, although comparison data are currently lacking. In this study we evaluated the Vigileo® (Edwards Lifesciences, Irvine, CA, USA) and USCOM® (USCOM Ltd, Sydney, NSW) devices in 62 critically ill patients requiring antibacterial therapy. The mean COVigileo and COUSCOM for the first paired measurements were 8.20±2.65 ***1/minute and 6.84±2.57 1/minute respectively (P P P P=0.066), although bias, precision and percentage error were similar in both subgroups. In 54 patients a second paired assessment was obtained at three hours. A weak, although significant correlation (r=0.377, P=0.005) was observed suggesting that gross trends over time were similar. In conclusion, our findings demonstrate poor agreement between these techniques suggesting that these devices are not simply interchangeable when assessing CO in a research or clinical setting.
Cerebrospinal Fluid Volume and Nerve Root Vulnerability during Lumbar Puncture or Spinal Anaesthesia at Different Vertebral Levels
Authors: Prats-Galino A. , Reina M. A. , Puigdellívol-Sánchez A. , Juanes Méndez J. A. , De Andrés J. A. , Collier C. B.
Published: January 2019

Cerebrospinal fluid (CSF) and nerve root volumes within the lumbosacral dural sac were estimated at various vertebral levels, in an attempt to determine any possible relevance to the incidence of nerve root trauma during lumbar puncture or spinal anaesthesia. Magnetic resonance images from seven patients were studied. Volumes were calculated by semi-automatic threshold segmentation combined with manual editing of each slice. The mean dural sac volume from S1 to T12 was 42.8±5.8 ml and the mean CSF volume 34.3±5.1 ml with the mean root volume being 10.4±2.2 cm3. The mean CSF volume per vertebral segment ranged from 4.3±0.7 ml at L5, to 5.8±2.5 ml at L1, with high inter-individual variability. The mean root volume ranged from 0.6±0.1 cm3 at L5 to 2.4±0.5 cm3 at T12.

The conus medullaris was located at L1 in four of the five patients scanned at upper lumbar levels, and at the lower border of L2 in the other. Vulnerability to nerve root damage was expressed as the Vulnerability Index (%), being defined as the ratio of root volume to dural sac volume (CSF volume + root volume). The value ranged between 7 and 14% at L5, increasing rostrally to 30 to 43% at T12. Caution is obviously required in high punctures to avoid contact with the conus medullaris, but the cauda equina is also vulnerable to contact with more caudal punctures and had a Vulnerability Index of about 25% at L4, that increased rostrally.
The Impact of Clinical Protocols in the Management of Severe Sepsis: A Prospective Cohort Study
Authors: Phua J. , Ho B. C. , Tee A. , Chan K. P. , Johan A. , Loo S. , Soh C. R. , Chia N. , Tan A. Y. , Tham H. M. , Chan Y. H. , Koh Y.
Published: January 2019

This study aimed to assess the availability of clinical protocols and their effect on compliance to the Surviving Sepsis Campaign bundles and on mortality in severe sepsis in ten Singaporean adult teaching intensive care units (ICU).

The presence of 11 protocols in the ICUs, steps taken based on the Johns Hopkins University Quality and Safety Research Group's model to translate protocols into practice, and organisational characteristics were assessed. Clinical and research personnel recorded characteristics of patients with severe sepsis who were admitted in July 2009, the achievement of sepsis bundle targets and outcomes.

Hospital mortality was 39% for 128 patients. Fewer than half of the ICUs had protocols for early goal-directed therapy, blood cultures, antibiotics, steroids, lung-protective ventilation and weaning. Compliance rates with the resuscitation and management bundles were 18 and 3% respectively. Units with protocols were generally not more likely to achieve associated bundle targets. Steps from the Johns Hopkins model to measure performance, engage teams and sustain and extend interventions were taken in fewer than half of the available protocols. However, on logistic regression analysis, the number of protocols available per ICU was independently and inversely associated with mortality.

In conclusion, clinical protocols are infrequently available in Singapore's ICUs and when present do not generally improve compliance to the sepsis bundles. These protocols may, however, be a surrogate marker of the quality of care as they are independently associated with decreased mortality. The use of an integrated and multifaceted approach to translate protocols into practice should be considered.
Assessment and Perceptions of Intensive Care Data Quality, Reporting and Use: A Survey of ICU Directors
Authors: Hewson-Conroy K. M. , Tierney L. T. , Burrell A. R.
Published: January 2019

It is becoming increasingly common for government bodies, healthcare providers, funders and consumers to seek measures of the quality of critical care. It is important to ensure the quality of intensive care unit (ICU) data is high so these stakeholders can confidently use quality of care measures in decision-making. This paper aims to evaluate the quality of data collected for and submitted to the Australian and New Zealand Intensive Care Society Adult Patient Database, and to investigate the perceptions of NSW ICU directors in relation to ICU data quality, reporting and usage. A survey tool was developed based on an existing framework that consisted of procedures for assessing data quality in medical registries. The survey was distributed to the directors of all NSW ICUs that submitted data in the 2007/2008 financial year. Overall, completeness of the data and its quality was perceived to be good. Participants were less likely to engage in activities involving the detection and correction of data errors, feedback of data or use of data for local purposes. A number of barriers and enablers to good quality ICU data as well as strategies to improve data quality were identified. Inadequate staff, training and resources for data collection were widespread concerns. NSW ICU directors believe more work is required to achieve high quality data and appropriate use of the data collected. Strategies targeting increased resources including updated technology and improved staffing and training, as well as low-cost solutions such as audit, feedback and clinician engagement, have been highlighted.
The Effect of Hair Colour on Anaesthetic Requirements and Recovery Time after Surgery
Authors: Myles P. S. , Buchanan F. F. , Bain C. R.
Published: January 2019

Patients with red hair are much more likely to have a variant of the melanocortin-1 receptor gene and this may affect sensitivity to general anaesthetics and pain response. We did a prospective, matched cohort study of 468 healthy adult patients undergoing general anaesthesia for elective surgery. All patients received an inhalational general anaesthetic. Anaesthetic drugs and doses used, hypnotic depth, recovery times, pain scores and quality of recovery scores were recorded. More men than women had red hair, so we did subgroup and multivariable analyses to account for this imbalance. There was no significant difference in recovery times, pain scores or quality of recovery scores in those with red hair. After adjusting for age, sex, American Society of Anesthesiologists physical status and duration of surgery, the recovery ratio for time to eye-opening in redheads was comparable to those with black or brown hair, 0.82 (0.57-1.19), P=0.30. We found no evidence that patient hair colour affects anaesthetic requirements or recovery characteristics in a broad range of surgical procedures.
Comparison of Evoked Electromyography in Three Muscles of the Hand during Recovery from Non-Depolarising Neuromuscular Blockade
Authors: Phillips S. , Stewart P. A. , Freelander N. , Heller G.
Published: January 2019

The evoked electromyographic responses to supramaximal train of four stimulation of three muscles, all innervated by the ulnar nerve, were compared during recovery from non-depolarising neuromuscular blockade. The abductor digiti minimi was the most resistant to neuromuscular blockade (P <0.001) and the most repeatable (repeatability coefficient 4.4%) when compared with the adductor pollicis (5.9%) and the first dorsal interosseous (5.8%). The abductor digiti minimi had a bias of 0.1 compared to the adductor pollicis and first dorsal interosseous and its limits of agreement were more acceptable (-0.10 to 0.30) at a train of four ratio of 0.9. The electromyography train of four of the adductor pollicis and first dorsal interosseous at 0.8 is equivalent to an electromyography train of four of 0.9 at abductor digiti minimi.
Influence of Major Cardiopulmonary Surgery on Serum Levels of Procalcitonin and Other Inflammatory Markers
Authors: Amin D. N. , Pruitt J. C. , Schuetz P.
Published: January 2019

Procalcitonin is a marker of significant bacterial infection. With Food and Drug Administration approval of a new high-sensitive procalcitonin assay in the United States, we felt it would be important to assess its normal elevation and time characteristics, as compared to other inflammatory markers in patients undergoing routine cardiac surgery. This is a prospective observational study including consecutive patients after routine cardiac surgery. Blood was sampled preoperatively, immediately postoperatively and daily until discharge or to postoperative day five for measurement of blood markers of infection. Patients were classified into different groups based on the type of surgery (on-pump and off-pump) and progression of recovery (complicated and uncomplicated). Patients after coronary artery bypass grafting off-pump (n=61) had significantly lower mean (0.90 vs 1.13 μg/l, P=0.006) and peak (2.09 vs 2.35 μg/l, P=0.002) procalcitonin levels in the postoperative course compared to patients with either on-pump valve surgery alone, on-pump coronary artery bypass grafting alone (n=28) or valve surgery with coronary artery bypass grafting (n=16). In addition, mean and peak procalcitonin levels were significantly higher (P=0.004 and P=0.002 respectively) in the 60 patients with a complicated course. This study provides insights into ‘normal’ kinetics of a new high-sensitive procalcitonin assay after different types of cardiac surgery, and in patients with and without a complicated postoperative course. Our results suggest that using a single procalcitonin level to guide antibiotic therapy decisions during the early period after major cardiac surgery may not be useful and that monitoring its kinetic may be the preferred strategy.