bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparison of Laryngeal Mask Airway with Tracheal Tube for Ophthalmic Surgery in Paediatric Patients
Authors: Gulati M. , Mohta M. , Ahuja S. , Gupta V. P.
Published: January 2019

This study of sixty ASA grade 1 or 2 children, aged 1 to 12 years, undergoing elective ophthalmic procedures, compared the use of the laryngeal mask airway (LMA) with that of an endotracheal tube. Changes in intraocular pressure and haemodynamic parameters, and intraoperative and postoperative complications were measured. Patients were randomly allocated into two groups of 30 patients. In group 1, the airway was secured with an LMA and in group 2 with an endotracheal tube. A standard technique of general anaesthesia incorporating positive pressure ventilation was used in both groups. The changes in intraocular pressure, heart rate (HR) and mean arterial pressure (MAP) were observed before and after insertion of the airway device, two minutes after insertion, and pre and post removal of the device. The incidence of airway complications was also noted. There was no significant change in mean intraocular pressure after insertion of the LMA, but removal caused a significant increase to 19.3± 7.6 mmHg (from a baseline of 13.9±4.3 mmHg). In the endotracheal tube group, intubation increased the mean intraocular pressure significantly to 19.9±7.3 mmHg (from a baseline of 13.1±4.0 mmHg) and extubation caused an increase to 24.6±10.4 mmHg which was clinically as well as statistically significant. The incidence of postoperative coughing was lower in the LMA group, but the incidence of vomiting higher. Two patients had displacement of the LMA during the procedure. We conclude that the use of an LMA is associated with less increase in intraocular pressure than the use of an endotracheal tube in children.
Recurrent Atrial Tachyarrhythmia Triggered by Percutaneous Balloon Rhizotomy of the Trigeminal Nerve
Authors: Fowler S. J. , Featherston M.
Published: January 2019

Stimulation of sensory branches of the trigeminal nerve is known to cause sudden bradycardia (trigeminocardiac reflex). However we report a case where percutaneous balloon rhizotomy of the trigeminal ganglion provoked atrial tachyarrhythmias during two separate treatments. On both occasions the patient was treated with antiarrhythmic drugs and reverted to sinus rhythm within days. Our case demonstrates that surgery involving the trigeminal nerve may cause variable cardiovascular effects that are often clinically significant. Possible mechanisms and management of arrhythmias in this setting are discussed.
Bilateral Adductor Vocal Cord Paresis following Endotracheal Intubation for General Anaesthesia
Authors: Wason R. , Gupta P. , Gogia A. R.
Published: January 2019

Recurrent laryngeal nerve palsy is a rare complication of endotracheal intubation. We report a case of bilateral vocal cord palsy following endotracheal intubation for general anaesthesia. The clinical picture was of hoarseness and aspiration suggesting partial paresis, as complete bilateral recurrent laryngeal nerve palsy usually causes acute airway obstruction due to unopposed vocal cord adduction. Compression of the anterior branch of the recurrent laryngeal nerve between the cuff of the endotracheal tube and the posterior part of the thyroid cartilage was the likely mechanism. Ensuring that the cuff of the endotracheal tube is distal to the cricoid cartilage and that the pressure in the cuff is kept to the minimum required to prevent a gas leak should prevent this complication.
Comparison of Disposable and Reusable Laryngeal Mask Airways in Spontaneously Ventilating Adult Patients
Authors: Cao M. M. , Webb T. , Bjorksten A. R.
Published: January 2019

Recent studies have indicated that despite stringent sterilization processes, the reusable silicone laryngeal mask airway (LMA) has the potential for disease transmission through residual biological debris. As a result, a polyvinyl chloride (PVC) disposable LMA has been introduced.

This randomized trial involved 138 spontaneously ventilating adult patients who underwent elective surgery requiring airway management with an LMA to determine whether there is a clinical difference between the disposable Portex® LMA (PLMA) and the standard reusable LMA in terms of ease of insertion, intra-operative cuff pressures and postoperative incidence of sore throat.

There was no significant difference in first attempt insertion success rates (79% vs 84%) or difference in the incidence of postoperative sore throat observed between the two groups. Cuff pressure increases with nitrous oxide anaesthesia were significantly larger with the reusable LMA. The disposable PLMA provided a suitable airway in spontaneously ventilating patients without the risk of disease transmission inherent in a reusable device.
The Use of the Laryngeal Mask in Gynaecological Laparoscopy
Authors: Viira D. , Myles P. S.
Published: January 2019

Use of the laryngeal mask airway in gynaecological laparoscopy is controversial, largely because of a concern about increased risk of regurgitation and pulmonary aspiration. The practice of evidence-based medicine provides a recommended strategy to resolve such an issue. We did a literature search and found limited evidence to support or refute the use of the LMA in this setting. We have found, however, that the reported incidence of aspiration or more serious morbidity associated with the use of the LMA in laparoscopic surgery is very low.
Survey of Intensive Care Nurses’ Knowledge Relating to the Pulmonary Artery Catheter
Authors: Johnston I. G. , Jane R. , Fraser J. F. , Kruger P. , Hickling K.
Published: January 2019

In 2003 there was an increase in the use of pulmonary artery catheters in Australia from 12,000 to 16,000 units in intensive care and peri-operative care. This survey of intensive care nurses in five intensive care units in Queensland addressed knowledge of use, safety and complications of the pulmonary artery catheter, using a previously validated 31 question multiple choice survey.

One hundred and thirty-nine questionnaires were completed, a response rate of 46%. The mean score was 13.3, standard deviation ±4.2 out of a total of 31 (42.8% correct). The range was 4 to 25. Scores were significantly higher in those participants with more ICU experience, higher nursing grade, a higher self-assessed level of knowledge and greater frequency of PAC supervision. There was no significant correlation between total score and hospital- or university-based education, or total score and public or private hospital participants. Fifty-one per cent were unable to correctly identify the significant pressure change as the catheter is advanced from the right ventricle to the pulmonary artery.
Systemic Lupus Erythematosus Complicated by HELLP Syndrome
Authors: Osmanagaoglu M. A. , Osmanagaoglu S. , Bozkaya H.
Published: January 2019

We describe a pregnant woman with systemic lupus erythematosus, complicated by severe pre-eclampsia (the HELLP syndrome) and adult respiratory distress syndrome, who died in the intensive care unit.

A 33-year-old multigravid woman was referred to our university hospital at 17 weeks’ gestation because of an exacerbation of systemic lupus erythematosus with elevated liver enzymes and thrombocytopenia. At the time of admission, on physical examination she had revealed a butterfly rash over the cheeks, purpura, acute synovitis and oedema of the legs. Her blood pressure was 180/100 mmHg. The initial laboratory tests and immunological evaluation confirmed active systemic lupus erythematosus complicated by severe pre-eclampsia. One week after admission, she became suddenly confused and had a convulsion with Glascow Coma Score 10 (3+3+4). Therapeutic abortion was induced in the Obstetric Department. She was transferred to the intensive care unit with a diagnosis of respiratory failure, probably due to acute respiratory distress syndrome, and was intubated and ventilated. Dialysis was instituted on two consecutive days from the eighth day. In total she received over 20 units of red blood cells and large quantities of fresh frozen plasma and platelets. On the 24th day her Glascow Coma Score was 2 (1+1+E) and severe hypotension developed. She died from worsening acute respiratory distress syndrome on the 25th day.

Women with systemic lupus erythematosus should be advised to become pregnant when the disease is inactive and should be observed at an appropriate centre using a multidisciplinary approach. Therapeutic abortion is an acceptable option if active nephropathy and severe pre-eclampsia are present in early pregnancy.
Tramadol Overdose and Serotonin Syndrome Manifesting as Acute Right Heart Dysfunction
Authors: Garrett P. M.
Published: January 2019

Acute right heart failure in a young person is an unusual presentation and drug overdose is a rare cause. A case is described where the patient presented with striking clinical signs of acute pulmonary hypertension and right heart failure, which were confirmed by transthoracic echocardiography. The precipitating event appeared to be poisoning by tramadol. There were features in keeping with tramadol toxicity and serotonin syndrome. The possible patho-physiology behind the process is discussed.
The Role of Microvascular Thrombosis in Sepsis
Authors: Dixon B.
Published: January 2019

The acute inflammatory response to sepsis gives rise to significant morbidity and mortality. The mechanisms underlying this form of tissue injury are poorly understood. This review examines the evidence that tissue ischaemia due, to generalized microvascular thrombosis may play an important role.

Microvascular thrombosis is probably an adaptive response that prevents bacteria in the tissues reaching the systemic circulation via the capillaries. In time, a definitive response by leucocytes removes the bacteria and repairs the damaged tissues. There is however evidence that if microvascular thrombosis becomes generalized, then extensive tissue ischaemia may precipitate organ failure and death.

Post-mortem studies of patients with sepsis demonstrate microvascular thrombi in many organs including the kidney, liver, lung, gut, adrenals and brain, and the degree of organ injury is related to the quantity of thrombi. Furthermore studies in human and animal models of sepsis demonstrate therapies that inhibit coagulation or promote fibrinolysis reduce organ failure and mortality.

In view of the personal and economic burdens that tissue injury associated with the acute inflammatory response places on the community, further studies to establish the role of microvascular thrombosis are clearly required. Such studies may lead to new therapies to limit or prevent this form of injury.
Intensive Care in Paradise—A Review of 57 Ventilated Patients in ICU in Vanuatu over Five Years
Authors: Grace R. F.
Published: January 2019

Intensive care is not a medical priority for developing nations. Vila Central Hospital is the major referral centre for the developing Pacific island nation of Vanuatu and runs an ‘as-needed’ intensive care service. Between January 1999 and January 2004, fifty-seven patients were ventilated at Vila Central Hospital. Twenty-two patients survived and 35 died. Eleven patients were declared brain dead, eight died from renal failure, six from overwhelming respiratory failure, three from sepsis, four due to equipment or technical failure, two of unknown causes and one died after transfer to Australia. The patient age range extended from newborns to 80 years. Survivors were ventilated for durations of four hours, (postoperative), to 14.5 days, (ARDS), the median being two days.
Early Experience with Magnesium Administration in Irukandji Syndrome
Authors: Corkeron M. , Pereira P. , Makrocanis C.
Published: January 2019

The administration of magnesium sulphate is a proposed novel therapy for Irukandji syndrome1. In this non-randomized, unblinded case series, data from ten patients who received magnesium salts are reviewed. Magnesium sulphate boluses of 10 to 20 mmol, in the six patients for which there was adequate data, reduced pain scores immediately after administration from 8.7±1.5 to 2.8±2.8 (Wilcoxon rank-sum test, P=0.03). In ten patients blood pressure decreased with a mean difference of −18 mmHg in mean arterial pressure. Magnesium requirements in individual patients varied markedly. Pain on injection occurred in four patients, three of whom had received peripherally administered magnesium chloride, and one patient reported transient ptosis after administration of magnesium sulphate 166 mmol over 18 hours in the setting of severe Irukandji syndrome.

Magnesium sulphate administration appears to attenuate pain and hypertension in Irukandji syndrome and warrants further evaluation in this setting.
Gum Elastic Bougie-guided Insertion of the ProSeal™ Laryngeal Mask Airway
Authors: Brimacombe J. , Keller C.
Published: January 2019

We tested the hypothesis that gum elastic-bougie-guided insertion of the ProSeal™ Laryngeal Mask Airway is more frequently successful than introducer tool guided insertion after failed digital insertion. One hundred anaesthetized patients (ASA 1-2, aged 18 to 80 years) were randomized for the second insertion attempt using either the gum elastic bougie-guided or introducer tool techniques. The bougie-guided technique involved priming the drain tube with the bougie, placing the bougie in the oesophagus using laryngoscope guidance, digital insertion along the palato-pharyngeal curve, and bougie removal. The introducer tool technique involved attaching the introducer tool, single-handed rotation along the palatopharyngeal curve, and introducer tool removal. Failed insertion was classified as (i) failed passage into the pharynx, (ii) malposition, or (iii) ineffective ventilation. Any blood staining was documented. Insertion was more frequently successful (50/50 vs 15/50, P=0.0002) and faster (35±17s vs 54±45s, mean±SD, P=0.006) with the bougie-guided technique. All failed insertions with the introducer tool technique were successful with the bougie-guided technique. The aetiology of failed insertion was similar for the digital and introducer tool techniques in 94% (33/35) of patients. There was no blood staining on the bougie, laryngoscope or introducer tool at removal, but blood staining was more common on the Proseal laryngeal mask airway with the introducer tool technique (9/50 vs 2/50, P=0.03). We conclude that the gum elastic bougie-guided insertion has a higher success rate and causes less trauma than the insertion tool insertion technique after failed digital insertion of the Proseal Laryngeal Mask Airway.
An Audit of the Single Use Portex Laryngeal Mask
Authors: Orlikowski C. E.
Published: January 2019

We performed an audit of the insertion of the Single Use Portex Laryngeal Mask in 400 patients. Insertion was successful at first attempt in 335 out of 400 patients (83.8%). However in 15 patients (3.8%), the Portex laryngeal mask could not be placed despite repeated attempts. In 12 of these 15 patients (80%), a standard Laryngeal Mask Airway (LMA) was successfully placed. After the completion of the audit, 22 out of 29 anaesthetists (75.9%), who had inserted 5 Portex laryngeal masks, considered it inferior to the standard LMA. It would appear to us that the Portex laryngeal mask might need some design modifications to be a real alternative to the standard LMA.
Metropolitan Audit of Appropriate Referrals Refused Admission to Intensive Care
Authors: Duke G. J.
Published: January 2019

We undertook a three-month prospective cohort study of critically ill adult patients referred to the Intensive Care Units 7(ICUs) of public hospitals in metropolitan Melbourne and Geelong, Victoria. The aim was to ascertain the prevalence and immediate consequences of “refused” admission amongst patients appropriately referred to the ICU of first choice.

Between August 1 and October 31, 1999, 10 (out of 12) public hospitals collected data. Three thousand and four patients were referred to these ICUs, and “refusals” were reported by all hospitals. A total of 282 (9.4%) patients were unable to be admitted to the ICU of first choice, giving a rate of 3.1 “refusals” per day. The reasons for “refusal” were limited staffing (52%) and shortage of beds (46%.) Acute inter-hospital transfer (1.7 per day) was the most common immediate triage outcome (57%). These rates are higher than previously reported figures.

We conclude that refused admission to the ICU of first choice, and acute inter-hospital transfer in this region and time period, were common events.
Dexmedetomidine Infusion without Loading Dose in Surgical Patients Requiring Mechanical Ventilation: Haemodynamic Effects and Efficacy
Authors: Ickeringill M. , Shehabi Y. , Adamson H. , Ruettimann U.
Published: January 2019

We investigated the haemodynamic effects and the efficacy of a continuous infusion of dexmedetomidine without a loading dose in 50 patients having had cardiac surgery (n=33), complex major surgery (n=9) and multiple trauma (n=8). The mean age was 60 (±16) years, and the mean APACHE II score was 13 (±5). Dexmedetomidine was commenced at an initial rate of 0.2 to 0.4 μg/kg/h (depending on whether anaesthetic or sedative agents had already been used) and rescue analgesia and sedation was administered with morphine and midazolam respectively. Propofol was used if additional sedation was needed. Sedation was targeted to a modified Motor Activity Assessment Score. Eighty percent of patients required no or “minimal” rescue therapy (<10 mg midazolam /day and/or <10 mg morphine/day and/or <100 mg propofol/day). The cardiac surgery group needed the least rescue therapy. A statistically significant but clinically unimportant reduction in mean heart rate and mean systolic blood pressure was observed over the first six hours (P<0.0001, and P=0.009 respectively). The baseline heart rate of 85 (±17) beats per minute (bpm), fell to a low of 78 (±13) bpm at four hours and then remained stable throughout the infusion period. The systolic blood pressure fell from 125 (±22) mmHg to a low of 112 (±20) mmHg at 1.5 hours with minimal change afterwards.

Dexmedetomidine was an effective sedative and analgesic in this group of complex surgical and trauma patients with pronounced benefit in the cardiac surgery group. Omitting the loading dose avoided undesirable haemodynamic effects without compromising sedation and analgesia.
The Use of Real Time rtPCR to Quantify Inflammatory Mediator Expression in Leukocytes from Patients with Severe Sepsis
Authors: Kalkoff M. , Cursons R. T. , Sleigh J. W. , Jacobson G. M.
Published: January 2019

Real-time reverse transcriptase polymerase chain reaction (RT rtPCR) was used to quantify the pattern of inflammatory mediator mRNA expression in circulating leukocytes from adult patients diagnosed with severe sepsis. We analysed 29 blood samples from 26 severely septic patients with different septic sources and eight samples from eight healthy adult volunteers. RT rtPCR was used to quantify mRNA expression of 21 different inflammatory mediators in peripheral leukocytes. The median variability in gene expression in the sepsis patients was 10.5 times greater than the variability of the healthy comparison group. We found a significant change in the regulation for the following genes: C5aR (20-fold, P<0.001), IL-8 (29-fold, P<0.001), MMP9 (72-fold, P<0.001), HSP70 (2.4-fold, P=0.02), and RIP2 (1.8-fold, P<0.04) were up-regulated. Conversely the median expression of IFNγ, and IL-6 were zero (P<0.001), and mtHSP (0.4-fold, P=0.02) was significantly down-regulated. Using linear discriminant analysis, IFNγ, IL-12, and TLR4 were correlated to a negative outcome. Different septic sources (peritonitis, burn, pneumonia and musculo-skeletal infections) resulted in significantly different mRNA patterns. The RT rtPCR is a useful tool to monitor the immune response in septic patients. We found a very high variability in inflammatory mediator expression among septic patients compared to healthy volunteers. This suggests that any future immune-modulatory therapy may need to be individualized to the patient's requirements as monitored by RT rtPCR. Different sources of sepsis may result in markedly different activation patterns.
Bloodless Intensive Care: A Case Series and Review of Jehovah's Witnesses in ICU
Authors: Maclaren G. , Anderson M.
Published: January 2019

The objective of this study was to assess the outcome of Jehovah's Witness (JW) patients admitted to a major Australasian ICU and to review the literature regarding the management of critically ill Jehovah's Witness patients.

All Jehovah's Witness patients admitted to the ICU between January 1999 and September 2003 were identified from a prospective database. Their ICU mortality, APACHE II scores, APACHE II risk of death and ICU length of stay were compared to the general ICU population. Twenty-one (0.24%) out of 8869 patients (excluding re-admissions) admitted to the ICU over this period were Jehovah's Witness patients. Their mean APACHE II score was 14.1 (±7.0), the mean APACHE II risk of death was 21.2% (±16.6), and the mean nadir haemoglobin (Hb) was 80.2 g/l (±36.4). Four out of 21 Jehovah's Witness patients died in ICU compared to 782 out of 8848 non- Jehovah's Witness patients (19.0% vs 8.8%, P=0.10, chi square). The median ICU length of stay in both groups was two days (P=0.64, Wilcoxon rank sum). The lowest Hb recorded in a survivor was 23 g/l.

Jehovah's Witness patients appear to be an uncommon patient population in a major Australasian ICU but are not over-represented when compared with their prevalence in the community. Despite similar severity of illness scores and predicted mortality to those in the general ICU population, there was a trend towards higher mortality in Jehovah's Witness patients.
Positive Pressure versus Pressure Support Ventilation at Different Levels of PEEP Using the ProSeal™ Laryngeal Mask Airway
Authors: Von Goedecke A. , Brimacombe J. , Keller C. , Hoermann C. , Loeckinger A. , Rieder J. , Kleinsasser A.
Published: January 2019

We compared positive pressure ventilation with pressure support ventilation at different levels of positive end expiratory pressure (PEEP) using the ProSeal laryngeal mask airway (PLMA). Forty-two anaesthetized adults (ASA 1-2, aged 19 to 63 years) underwent positive pressure ventilation and then pressure support ventilation each with PEEP set at 0, 5 and 10 cmH2O in random order. Pressure support ventilation was with the inspired tidal volume (VTInsp) set at 7 ml/kg and the respiratory rate adjusted to maintain the end-tidal CO2 (ETCO2) at 40 mmHg. Pressure support ventilation was with pressure support set at 5 cmH2O above PEEP and initiated when inspiration produced a 2 cmH2O reduction in airway pressure. Tidal volumes were similar during positive pressure and pressure support ventilation with PEEP, but were higher for the former without PEEP. Respiratory rate and peak inspiratory flow rate were higher during pressure support than positive pressure ventilation (all P<0.001). Peak airway pressure (Ppaw), mean airway pressure (Mpaw), peak expiratory flow rate, and expired airway resistance were lower during pressure support than positive pressure ventilation (all P<0.001). With PEEP set at 10 cmH2O, ETCO2 was lower for pressure support than positive pressure ventilation. During positive pressure ventilation, there was an increase in Ppaw, Mpaw and dynamic compliance (Cdyn) with increasing levels of PEEP (all P<0.01). During pressure support ventilation, there was an increase in inspired and expired tidal volume, Ppaw, peak inspiratory and expiratory flow rates and Cdyn, and a reduction in ETCO2, work of breathing, and expired airway resistance with increasing levels of PEEP (all P<0.01). There were no differences in SpO2, non-invasive mean arterial pressure, heart rate or leak fraction. We conclude that pressure support ventilation provides equally effective gas exchange as positive pressure ventilation during PLMA anaesthesia with or without PEEP at the tested settings. During pressure support, PEEP increases ventilation and reduces work on breathing without increasing leak fraction.
Epidural Analgesia Associated with a Fatal Outcome in a Patient with an Unrecognized Brain Tumour
Authors: Tsai H. J. , Tsou M. Y. , Ho C. M. , Tsai S. K.
Published: January 2019

A fatality associated with epidural analgesia in a patient with an unsuspected brain tumour has not been reported in the literature. We describe a case of postoperative lumbar epidural analgesia in a 54-year-old female patient who had an undiagnosed brain tumour and a fatal outcome postoperatively. The factors that potentially contributed to this mishap and the possible alternative management of this patient are discussed.
Seizures and the Pituitary Gland during Pregnancy
Authors: Wilkinson D. A. , Popham P. A.
Published: January 2019

We present the anaesthetic management of a woman who, at 10 days post partum, suffered a series of convulsions in the context of two episodes of post partum haemorrhage. The probable aetiology of the convulsions is discussed.
Comparison of Forced-air Warming and Radiant Heating during Transurethral Prostatic Resection under Spinal Anaesthesia
Authors: Torrie J. J. , Yip P. , Robinson E.
Published: January 2019

Forced-air warming is commonly used to warm patients intraoperatively, but may not achieve normothermia during a short procedure. Comparative trials of a new radiant warming device in general anaesthesia (Suntouch™, Fisher and Paykel, Auckland, New Zealand) have had conflicting results. We conducted a randomized controlled trial to compare the efficacy and thermal comfort of the Suntouch™ radiant warmer and forced-air warming in patients at high risk of hypothermia during neuraxial blockade. With ethics committee approval, 60 patients having transurethral resection of the prostate under spinal were randomized to either radiant warming or forced-air warming. All intravenous and irrigation fluids were warmed but pre-warming was not used. The final intraoperative rectal temperatures for the radiant warming and forced-air warming groups were 36.1°C and 36.4°C respectively (P=0.03). A large proportion of patients in both groups (46% and 33% respectively, P=0.3) were hypothermic (<36°C) on arrival in the post-anaesthesia care unit. No other patient variables were significantly different. Neither warming device reliably prevented hypothermia, although forced-air warming was slightly superior.
Long-term Survival of Surgically Treated Hip Fracture in an Australian Regional Hospital
Authors: Mcleod K. , Brodie M. P. , Fahey P. P. , Gray R. A.
Published: January 2019

This study was undertaken to identify factors influencing outcome in elderly patients operated for hip fracture. In particular, this study examined factors related to mortality at least 30 months post-fracture. Hospital records and death registrations were analysed for 463 patients aged 60 or more years treated for hip fracture at a Queensland regional hospital between 1997 and 2001. The overall mortality for surgically treated patients was 13.7% at 100 days and 24.9% at one year. Patient factors including age, gender, health status and place of residence were the predominant influences on mortality. Non-patient and process factors including delay to surgery, type of operation and type of anaesthetic had minimal impact on mortality. No major determinants of length of hospital stay were identified. Patient health status was the main determinant for surgical delay. Our results confirm the persistently high mortality in this group of patients, and suggest that the main determinants of outcome are patient- rather than process-related.
Debriefing after Critical Incidents for Anaesthetic Trainees
Authors: Tan H.
Published: January 2019

This survey investigated the need, and the availability, of debriefing after critical incidents for training anaesthetists. A cross-sectional postal survey of all Australian anaesthetic trainees was conducted in May 2002. Four hundred and nineteen responses were analysed (response rate 64%). Debriefing after a critical incident was perceived by most trainees to be useful, however 36% (n=149) had never been debriefed. Trainees ranked their preferred content for a debriefing as ‘anaesthetic issues’ followed by the ‘psychological impact of the incident’, ‘patient issues’ and ‘surgical issues’. Almost half of respondents reported that they did not feel supported by their anaesthetic department after a negative outcome incident. Trainees who had debriefings were more likely to feel supported by senior colleagues. Debriefing after critical incidents should be an integral part of the supervision of anaesthetic trainees.
Fibreoptic Intubation Skills among Anaesthetists in New Zealand
Authors: Dawson A. J. , Marsland C. , Baker P. , Anderson B. J.
Published: January 2019

The aim of this study was to investigate methods of practice, assess skill level, and evaluate attitudes towards fibreoptic intubation in the anaesthetic community of New Zealand. A postal survey questionnaire was sent to all vocationally registered anaesthetists in New Zealand and to all New Zealand anaesthetic trainees registered with the Australian and New Zealand College of Anaesthetists. There were 611 survey questionnaires posted and 386 (63%) respondents. Almost all respondents (98% of specialists, 100% of trainees) had access to fibreoptic equipment in public and 92% of respondents performed fibreoptic intubation. The median number of fibreoptic intubations performed per year was 3 for consultants and 4 for trainees. Respondents were either self taught or colleague taught (82%). Most learnt the technique on patients (92%). There were 14% who considered themselves experienced, 30% competent, 34% adequate and 20% novice. Skills were maintained by clinical patient mix in 73%. Fibreoptic intubation was considered a skill required by all anaesthetists in 87%, and 66% considered it the gold standard for expected difficult airways. Lack of clinical cases requiring the skill and lack of practice were identified as the primary barriers to skill development. Consultants had greater opportunity to learn fibreoptic intubation skills during daily practice than trainees. Only 18% of trainees had a formal airway management program available to them at their place of work. There appears to be a need to increase available opportunities to perform fibreoptic intubation to enable maintenance and improvement of fibreoptic skills in our community. A formalized program of teaching fibreoptic intubation may offer greater opportunity for learning and skill development.
The Theoretical Basis for Using Apnoeic Oxygenation via the Non-ventilated Lung during One-lung Ventilation to Delay the Onset of Arterial Hypoxaemia
Authors: Pfitzner J. , Pfitzner L.
Published: January 2019

At the time one-lung ventilation is initiated, nitrogen from the atmosphere may enter the non-ventilated lung via a double-lumen tube connector that has been left open to air, even momentarily. Ongoing oxygen uptake from the non-ventilated lung raises the partial pressure of nitrogen. This should lead to activation of hypoxic pulmonary vasoconstriction and a reduction in intra-pulmonary shunting. However, in spite of this, some patients still become hypoxaemic. In such cases, it may be advantageous to have excluded nitrogen from the non-ventilated lung by connecting it to an oxygen source at ambient pressure. Ongoing apnoeic oxygenation, while the airways are patent, and as the lung collapses, should delay the onset of arterial desaturation. In this paper we review the theoretical basis for apnoeic oxygenation during one-lung ventilation, and in particular on oxygen uptake by the non-ventilated lung prior to and during its subsequent collapse.
Tetanus in a Subcutaneous Drug Abuser: Ineffectiveness of Intrathecal Baclofen
Authors: Thomas R. M. , Bellamy M. C.
Published: January 2019

This report discusses the issues involved in the diagnosis and management of tetanus. A 29-year-old female with a history of illicit drug use presented with progressive tetany secondary to an abscess on her forearm from subcutaneous injections. She was managed in the intensive care unit for 29 days and was discharged to the ward. The main issue in her management was control of tetanic episodes interfering with ventilation and resistant to intrathecal baclofen. Other therapeutic strategies aimed at reducing spasms included magnesium, atracurium, pancuronium, midazolam, propofol and dantrolene. We conducted searches on Medline, PUBMED and the Cochrane Database of Systematic Reviews using the following terms: tetanus, treatment, therapy, drug abuse, magnesium, baclofen and human anti-tetanus immunoglobulin (hAIG). The current strategies involved in treating tetanus are discussed.
Anaesthesia for Implantation of the Jarvik 2000 Flowmaker® LVAD
Authors: Tan L. H. , Cokis C.
Published: January 2019

The Jarvik 2000 Flowmaker® is an intraventricular continuous axial flow left ventricular assist device. We describe the anaesthetic management and considerations for five patients with end-stage heart failure who underwent implantation of the Jarvik 2000 Flowmaker® as a bridge to transplantation or as destination therapy.
Adenotonsillar Surgery in Morbidly Obese Children: Routine Elective Admission of all Patients to the Intensive Care Unit is Unnecessary
Authors: Shine N. P. , Coates H. L. , Lannigan F. J. , Duncan A. W.
Published: January 2019

Morbidly obese children undergoing adenotonsillectomy, often with co-morbid obstructive sleep apnoea, may be considered at a higher risk of postoperative respiratory compromise. This retrospective study aimed to assess the frequency and severity of postoperative respiratory complications in these patients and to identify preoperative risks factors for such morbidity. Medical and nursing chart review of all consecutive elective post-adenotonsillectomy admissions of morbidly obese children (defined as >95th centile for body mass index adjusted for age and gender) to our intensive care unit over a 30-month period was performed. A total of 26 morbidly obese children were identified. The majority (14/26) had an uncomplicated recovery following surgery. Of those cases that required postoperative intervention, 10 patients required supplemental oxygen with or without suctioning and/or repositioning alone, whilst two required continuous positive airway pressure therapy. No patient required re-intubation. An oxygen saturation nadir of <70% and the presence of more than one central apnoea, noted on preoperative overnight polysomnography, were associated with postoperative respiratory complications requiring intervention. Although the intervention group were younger, more obese and had a higher respiratory disturbance index, none of these factors were statistically significant. Routine admission to the paediatric intensive care unit of all morbidly obese children undergoing adenotonsillectomy may be unnecessary, once a suitable high level of nursing is available in an alternative setting, to administer simple positional and suctioning intervention and to perform regular patient observation. Special consideration should be given to the postoperative nursing environment for those patients with a SaO2 nadir <70% noted preoperatively, indicating the presence of a significant central disease component.
General Practitioner Anaesthesia Survey 2006
Authors: Davie M. J.
Published: January 2019

A survey was posted to all general practitioner anaesthetists in Australia who are currently involved in the Joint Consultative Committee on Anaesthesia (JCCA) accreditation process known as the Maintenance of Professional Standards program (MOPS). The survey was intended to gain information regarding accreditation, continuing medical education, caseloads, on call, work practices, attitudes and future work plans. The response rate was 70% (168/240). The majority of respondents worked in a rural location (73%) where there were no specialist anaesthetists (74%). Of the respondents, 89 were category A accredited, but only 15% had this based on completion of the Advanced Rural Skills Curriculum Statement in Anaesthesia (ARSCSA) and examination. The mean number of sessions in anaesthesia worked per week was 2.8 (SD 2.2). Of the respondents, 69% administered more than 150 anaesthetics per year: 28% were on call more than 10 times per month. General surgery, gastrointestinal endoscopy, obstetrics, gynaecology and orthopaedics were the most common specialties for which anaesthesia was provided. Eight percent of respondents stated that sedation comprised 81–100% of their caseload: 92% used propofol as part of their usual intravenous sedation technique: 90% provided anaesthesia for paediatric patients with a mean minimum age of 4.1 years (SD 3.4): 64% provided epidural anaesthesia/analgesia. The majority stated that specialist anaesthetists and hospital administrations were helpful and supportive. Eighty-two percent planned to continue or increase their current anaesthetic workload over the next five years. The JCCA MOPS program appears to provide a satisfactory pathway for training, accreditation and on-going education of general practitioner anaesthetists.
Some Observations on Early Military Anaesthesia
Authors: Houghton I. T.
Published: January 2019

Although anaesthesia was discovered in 1846, pain relief had been used for many years previously. Opium, mandragora, and Indian hemp amongst others have been used since the earliest times as alluded to by many of the classical writers. The use of refrigeration anaesthesia is known to have been recommended a millennium ago although it never had much usage.

Very soon after the introduction of ether anaesthesia, it was recommended for military use and the first use by the American forces was in Buena Vista early in 1847 and then again at Vera Cruz. Pirogoff taught and used ether anaesthesia on active service with the Russian forces in the Caucasus in the summer of 1847. Meanwhile Spencer Wells, who was serving with the Royal Navy in Malta, was the first British service medical officer recorded to have used anaesthesia. He went on to write up a series of 106 anaesthetics.

The Danes were probably next to use anaesthesia in battle using chloroform in 1848. However, it was not until the Crimean War that anaesthesia began to play an important part in battle surgery with many anaesthetics being given with varying results.

The War of the Rebellion was the next war in which anaesthesia was important and the first one in which proper statistics were kept allowing useful analysis. Anaesthesia had irrevocably found its place in battlefield surgery.
Drug Abuse and Dependency during Pregnancy: Anaesthetic Issues
Authors: Ludlow J. , Chrislmas L. , Paech M. J. , Orr B.
Published: January 2019

Drug abuse is a significant social problem that can lead to serious obstetric complications, some of which may be confused with pregnancy-related disease states. Substance abuse poses a number of challenges with respect to the management of pain and the conduct of anaesthesia in the peripartum period.

This review was based on information from a literature search of epidemiological, research and review papers on substance abuse during pregnancy, obtained for the purpose of preparing a background paper for the Ministerial Council on Drug Strategy, Commonwealth Government of Australia.

Given that almost 80% of substance-abusing parturients require anaesthetic services in the perinatal period, early antenatal referral for anaesthetic review is recommended. To optimise the care of these vulnerable patients, obstetricians, general practitioners and midwives should attempt to identify substance-abusing parturients and refer them to an anaesthetist. A careful anaesthetic evaluation with non-judgemental questioning is essential, with management tailored to individual patient needs and the urgency of obstetric intervention for vaginal delivery or caesarean section.

Opioid-dependent women, in particular, benefit from antenatal pain management planning. Patients recovering from drug addiction should also have a well-documented analgesic strategy. A multidisciplinary approach will involve obstetricians, anaesthetists and staff of the Drug and Alcohol Service. In acute admissions of women by whom antenatal care was not accessed, a high index of suspicion for illicit drug use should arise. Because illicit substance use is so prevalent, if untoward reactions occur during an otherwise uneventful anaesthetic, the possibility of drug abuse should be considered.
USCOM (Ultrasonic Cardiac Output Monitors) Lacks Agreement with Thermodilution Cardiac Output and Transoesophageal Echocardiography Valve Measurements
Authors: Van Den Oever H. L. A. , Murphy E. J. , Christie-Taylor G. A.
Published: January 2019

The USCOM (Ultrasonic Cardiac Output Monitors) device is a noninvasive cardiac output monitor, which utilises transaortic or transpulmonary Doppler flow tracing and valve area estimated using patient height to determine cardiac output. We evaluated USCOM against thermodilution cardiac outputs and transoesophageal echocardiography valve area measurements in 22 ASA PS4 cardiac surgical patients. Data collection commenced following pulmonary artery catheter insertion, with cardiac output measurements repeated after sternotomy closure. Failure to obtain transaortic Doppler readings using USCOM occurred in 5% of planned measurements. USCOM transaortic analysis was not planned for 11 patients with known aortic disease. Bias at the aortic window (n = 20) was -0.79 l/min with limits of agreement from -3.66 to 2.08 l/min. At the pulmonary window, failure to obtain Doppler readings occurred in 24% of planned measurements. Bias at the pulmonary window (n=36) was -0.17 l/min with limits of agreement from -3.30 to 2.97 l/min. The USCOM estimates of valve area based on height showed poor correlation with the echocardiographic measurements of aortic and pulmonary valves (r=0.57 and r=0.17, respectively). It was concluded that USCOM showed poor agreement with thermodilution. The estimated valve area was identified as one source of error.
Continuous Venovenous Haemofiltration Attenuates Myocardial Mitochondrial Respiratory Chain Complexes Activity in Porcine Septic Shock
Authors: Li C.-M. , Chen J.-H. , Zhang P. , He Q. , Yuan J. , Chen R. J. , Cheng X.-J. , Tan H.-Z. , Yang Y.
Published: January 2019

Increasing evidence indicates that mitochondrial dysfunction plays an important role in modulating the development of septic shock. In the present study, we investigated whether continuous venovenous haemofiltration (CVVH) with high-volume might improve myocardial mitochondrial dysfunction in a porcine model of peritonitis-induced septic shock. Sixteen male Landrace pigs weighing 31 ±5 kg were randomly assigned to normal control group (n=4), peritonitis group (n = 6) and peritonitis plus CVVH group (n = 6). All animals were anaesthetised and mechanically ventilated. After baseline examinations, the peritonitis group and the peritonitis plus CVVH group underwent induction of peritonitis. One hour later, the animals in the peritonitis plus CVVH group received treatment with high-volume CWH. Twelve hours after treatment, the animals were sacrificed. Animals in the peritonitis group were killed 13 hours after induction of peritonitis. Peritonitis challenge induced septic shock associated with increased blood lactate and high-volume CVVH improved lactate acidosis. Compared with the peritonitis group, cardiac output, stroke volume and mean arterial pressure were better maintained in peritonitis plus CVVH group. More importantly, high-volume CVVH improved myocardial mitochondrial complex I activity (0.22 ± 0.03 vs. 0.15 ± 0.04, P = 0.04). These results suggest that high-volume CVVH improves haemodynamics and heart dysfunction in septic shock and the improvement may be attributed to amelioration of myocardial mitochondrial dysfunction.
A Comparison of 4% Succinylated Gelatin Solution versus Normal Saline in Stable Normovolaemic Sheep: Global Haemodynamic, Regional Blood Flow and Oxygen Delivery Effects
Authors: Wan L. , Bellomo R. , May C. N.
Published: January 2019

The objective of this study was to compare the effects on regional blood flow and regional oxygen delivery of 4% succinylated gelatin solution (Gelofusine®, B. Braun) with those of normal saline. This was a randomised, controlled, crossover large animal study, which took place at the animal laboratory of university physiology institute. The subjects were seven merino cross-ewes.

We implanted flow probes around the aorta, coronary, renal and mesenteric arteries. We randomised animals to observation (control), normal saline (one litre over 15 minutes) or Gelofusine* (one litre over 15 minutes). We measured central haemodynamics, organ blood flows, arterial blood gases and haemoglobin every 30 minutes for 210 minutes.

Compared to control, both Gelofusine* and normal saline significantly and similarly increased mean arterial pressure, stroke volume, cardiac output and central venous pressure in the first hour (P <0.05). Such changes, however, were transient except for the increase in cardiac output seen with Gelofusine®. Normal saline significantly increased mesenteric blood flow in the first hour (P <0.05), while Gelofusine* caused a specific, sustained and progressive increase in renal blood flow and conductance (P <0.05). Both fluids increased urine output and creatinine clearance (P <0.05), but, due to haemodilution, both decreased renal oxygen delivery in the first hour (P <0.05).

Normal saline and Gelofusine® have transient, volume expansion-related systemic haemodynamic effects, which are greater for Gelofusine®. Saline had a more pronounced early effect on mesenteric blood flow, while Gelofusine* had a sustained and progressive greater effect on renal blood flow. The transient increase in urine output and creatinine clearance seen with both fluids occurred while renal oxygen delivery decreased.
Effectiveness of Superior versus Inferior Subconjunctival Anaesthesia for Cataract Surgery
Authors: Yuen J. S. , Prineas S. , Pham T. , Liu H.
Published: January 2019

This study compared the efficacy of two different injection sites for subconjunctival anaesthesia (SCA) in cataract surgery. One-hundred-and-three eyes of 99 consecutive patients undergoing routine cataract surgery were randomised to receive SCA either to the superior bulbar conjunctiva (n=52) or the inferior bulbar conjunctiva (n=51). Pain experienced during anaesthetic administration and at various stages of the perioperative period was assessed using a simplified scale. Assessment of subconjunctival haemorrhage and chemosis was made by the surgeon. The percentage of patients reporting any pain on administration of superior SCA was 46% compared to 67% with inferior SCA (P=0.036). Moderate to severe pain on SCA injection was experienced by 15% and 18% of those in the superior and inferior SCA groups respectively. The cataract procedure was well tolerated in both groups. There was no difference between the groups for duration of surgery (P =0.25), anaesthetic related complications including chemosis (P =0.28), subconjunctival haemorrhage (P=0.38) or intraoperative complications (P =0.50).

We found that subconjunctival anaesthesia is effective for routine cataract surgery. There was no difference in block efficacy between superiorly and inferiorly delivered SCA. However, superior SCA appeared to be less painful on injection compared to inferiorly delivered SCA.