bluuebunny/crossref_metadata_2025 huggingface dataset:
The Spectrum of Practice in the Diagnosis and Management of Pneumonia in Patients Requiring Mechanical Ventilation. Australian and New Zealand Practice in Intensive Care (ANZPIC II)
Authors: Boots R. J. , Lipman J. , Bellomo R. , Stephens D. , Heller R. F.
Published: January 2019

This study of ventilated patients investigated current clinical practice in 476 episodes of pneumonia (48% community-acquired pneumonia, 24% hospital-acquired pneumonia, 28% ventilator-associated pneumonia) using a prospective survey in 14 intensive care units (ICUs) within Australia and New Zealand. Diagnostic methods and confidence, disease severity, microbiology and antibiotic use were assessed.

All pneumonia types had similar mortality (community-acquired pneumonia 33%, hospital-acquired pneumonia 37% and ventilator-associated pneumonia 24%, P=0.15) with no inter-hospital differences (P=0.08–0.91). Bronchoscopy was performed in 26%, its use predicted by admission hospital (one tertiary: OR 9.98, CI 95% 5.11–19.49, P<0.001; one regional: OR 6.29, CI 95% 3.24–12.20, P<0.001), clinical signs of consolidation (OR 3.72, CI 95% 2.09–6.62, P<0.001) and diagnostic confidence (OR 2.19, CI 95% 1.29–3.72, P=0.004). Bronchoscopy did not predict outcome (P=0.11) or appropriate antibiotic selection (P=0.69). Inappropriate antibiotic prescription was similar for all pneumonia types (11–13%, P=0.12) and hospitals (0–16%, P=0.25). Blood cultures were taken in 51% of cases. For community-acquired pneumonia, 70% received a third generation cephalosporin and 65% a macrolide. Third generation cephalosporins were less frequently used for mild infections (OR 0.38, CI 95% 0.16–0.90, P=0.03), hospital-acquired pneumonia (OR 0.40, CI 95% 0.23–0.72, P<0.01), ventilator-associated pneumonia (OR 0.04, CI 95% 0.02–0.13, P<0.001), suspected aspiration (OR 0.20, CI 95% 0.04–0.92, P=0.04), in one regional (OR 0.26, CI 95% 0.07–0.97, P=0.05) and one tertiary hospital (OR 0.14, CI 95% 0.03–0.73, P=0.02) but were more commonly used in older patients (OR 1.02, CI 95% 1.01–1.03, P=0.01).

There is practice variability in bronchoscopy and antibiotic use for pneumonia in Australian and New Zealand ICUs without significant impact on patient outcome, as the prevalence of inappropriate antibiotic prescription is low. There are opportunities for improving microbiological diagnostic work-up for isolation of aetiological pathogens.
Disease Risk and Mortality Prediction in Intensive Care Patients with Pneumonia. Australian and New Zealand Practice in Intensive Care (ANZPIC II)
Authors: Boots R. J. , Lipman J. , Bellomo R. , Stephens D. , Heller R. F.
Published: January 2019

This study of ventilated patients investigated pneumonia risk factors and outcome predictors in 476 episodes of pneumonia (48% community-acquired pneumonia, 24% hospital-acquired pneumonia, 28% ventilator-associated pneumonia) using a prospective survey in 14 intensive care units within Australia and New Zealand. For community acquired pneumonia, mortality increased with immunosuppression (OR 5.32, CI 95% 1.58–17.99, P<0.01), clinical signs of consolidation (OR 2.43, CI 95% 1.09–5.44, P=0.03) and Sepsis-Related Organ Failure Assessment (SOFA) scores (OR 1.19, CI 95% 1.08–1.30, P<0.001) but improved if appropriate antibiotic changes were made within three days of intensive care unit admission (OR 0.42, CI 95% 0.20–0.86, P=0.02). For hospital-acquired pneumonia, immunosuppression (OR 6.98, CI 95% 1.16–42.2, P=0.03) and non-metastatic cancer (OR 3.78, CI 95% 1.20–11.93, P=0.02) were the principal mortality predictors. Alcoholism (OR 7.80, CI 95% 1.20–17.50, P<0.001), high SOFA scores (OR 1.44, CI 95% 1.20–1.75, P=0.001) and the isolation of “high risk” organisms including Pseudomonas aeruginosa, Acinetobacter spp, Stenotrophomonas spp and methicillin resistant Staphylococcus aureus (OR 4.79, CI 95% 1.43–16.03, P=0.01), were associated with increased mortality in ventilator-associated pneumonia. The use of non-invasive ventilation was independently protective against mortality for patients with community-acquired and hospital-acquired pneumonia (OR 0.35, CI 95% 0.18–0.68, P=0.002). Mortality was similar for patients requiring both invasive and non-invasive ventilation and non-invasive ventilation alone (21% compared with 20% respectively, P=0.56).

Pneumonia risks and mortality predictors in Australian and New Zealand ICUs vary with pneumonia type. A history of alcoholism is a major risk factor for mortality in ventilator-associated pneumonia, greater in magnitude than the mortality effect of immunosuppression in hospital-acquired pneumonia or community-acquired pneumonia. Non-invasive ventilation is associated with reduced ICU mortality. Clinical signs of consolidation worsen, while rationalising antibiotic therapy within three days of ICU admission improves mortality for community-acquired pneumonia patients.
Comparison of Oxygen Cost of Breathing between Pressure-Support Ventilation and Airway Pressure Release Ventilation
Authors: Uyar M. , Demirag K. , Olgun E. , Cankayali I. , Moral A. R.
Published: January 2019

We compared the oxygen cost of breathing between pressure-support ventilation (PSV) and airway pressure release ventilation (APRV). This prospective, randomized, crossover study was conducted in a mixed ICU of a university hospital. Twenty clinically stable and spontaneously breathing patients after long-term mechanical ventilation were included. The patients were randomized to start on either PSV or APRV mode and measurements were obtained after an adaptation period of 30 minutes with a PaCO2 between 35–45 mmHg and PaO2 above 60 mmHg. Patients were then switched to the other mode and the same measurements were repeated. Indirect calorimetry was performed during each ventilatory mode for a period of 30 minutes. Oxygen consumption, energy expenditure, CO2 production, and respiratory quotient were measured. The parameters did not differ significantly between the two ventilatory modes, regardless of the patient's randomization. There were no statistically significant differences with regard to respiratory rate, minute volume, and blood gas analysis. All patients tolerated both ventilatory modes without signs of discomfort. PSV and APRV produced similar results in terms of oxygen cost of breathing and other metabolic variables.
Anaesthetic Adverse Incident Reports: An Australian Study of 1,231 Outcomes
Authors: Aders A. , Aders H.
Published: January 2019

While there have been previous studies looking at patterns of litigation against anaesthetists overseas, there is little reported on the trends in Australia. This study was performed to ascertain current reporting rates of anaesthetic incidents, and from what areas these reports arise. Over the five years spanning January 1999 until December 2003, 1,231 adverse anaesthetic outcomes were reported to United Medical Protection by Australian anaesthetists. As in other studies, damage relating to airway instrumentation was the most frequently reported, comprising 261 incidents (21.8%). Complications related to epidural blockade were the next most common, accounting for 182 outcomes (15.2%). Other common areas generating incident reports included nerve injuries, respiratory complications, drug side-effects and death. To date 147 claims (12.3%) have arisen from these incident reports. Knowledge of these areas of risk should translate into more effective risk management with reduction in claims and adverse patient outcomes.
Control of Imported and Acquired Methicillin-resistant Staphylococcus aureus (MRSA) in Mechanically Ventilated Patients: A Dose-response Study of Enteral Vancomycin to Reduce Absolute Carriage and Infection
Authors: Viviani M. , Van Saene H. K. F. , Dezzoni R. , Silvestri L. , Lenarda R. Di , Berlot G. , Gullo A.
Published: January 2019

This study aimed to quantify the animate source provided by the patients using the concept of “absolute carriage” by multiplying the carrier rate by the level of carriage; and to compare the impact of a low and high dose of an oropha-ryngeal vancomycin gel on the absolute MRSA carriage and infection.

In all, 265 patients were included, 126 were MRSA positive. Fifty-five patients received 2% vancomycin gel during the first year whilst 4% vancomycin gel was given to 50 patients during the second year. Surveillance swabs of throat and rectum were obtained from all eligible patients on admission and then twice weekly. The vancomycin protocol was started as soon as the surveillance cultures were positive for MRSA. Those patients received one gram of enteral vancomycin daily, divided into four doses. During the first year 2% vancomycin gel 4 ml (80 mg) was applied in the oropharynx in four doses in addition to the enteral solution (Group A). During the second year 4% vancomycin gel 4 ml (160 mg) was used (Group B).

The absolute carriage was high during both periods: 3.6 for Group A, and 3.2 for Group B. The 4% vancomycin protocol significantly reduced the absolute carriage, compared to the 2% vancomycin protocol: 2.6 versus 1.5 (P<0.01). Significant reduction in secondary endogenous infections was found in the second year: seven versus 15 patients (P<0.05). A total of 3,588 microbiological samples were processed. Neither Staphylococcus aureus with intermediate sensitivity to vancomycin (VISA) nor vancomycin-resistant enterococci (VRE) were detected.
Severe Hypotension and Hepatic Dysfunction in a Patient Undergoing Scoliosis Surgery in the Prone Position
Authors: Yuen V. M. Y. , Chow B. F. M. , Irwin M. G.
Published: January 2019

Many patients with neuromuscular disorders develop progressive scoliosis and require corrective surgery. We present a patient with hereditary motor and sensory neuropathies who developed severe hypotension during corrective surgery for thoracolumbar scoliosis. The haemodynamic disturbance was probably secondary to thoracic hyperlordosis and the knee-chest position and was aggravated by surgical manipulation. This may be prevented by tailored preoperative evaluation of different patient prone position supports and frames in order to select that which causes least cardiovascular and respiratory disturbance. This patient also developed severely deranged liver function postoperatively and the possible aetiology is discussed.
Pulmonary Arteriovenous Malformation Causing Massive Haemoptysis and Complicated by Coronary Air Embolism
Authors: Loke G. P. Y. , Story D. A. , Liskaser F. , Seevanayagam S.
Published: January 2019

We report the case of a 20-year-old man with possible Osler-Rendu-Weber syndrome (hereditary haemorrhagic telangiectasia) who developed an episode of massive haemoptysis from a bleeding pulmonary arteriovenous malformation in the left lower lobe of his lung. During the acute haemorrhage, he also appeared to suffer a coronary air embolism, possibly due to introduction of air into the bleeding arteriovenous malformation during intermittent positive pressure ventilation through the endotracheal tube. His electrocardiogram showed extensive ST elevation (>2 mm) in the inferolateral leads associated with raised troponin I and creatine kinase levels. These changes resolved within thirty minutes. The pulmonary arteriovenous malformation was successfully treated with a combination of alcohol injection and coil embolization.
A National Survey of Infection Control Practice by New Zealand Anaesthetists
Authors: Ryan A. J. , Webster C. S. , Merry A. F. , Grieve D. J.
Published: January 2019

Anaesthetists have an important role in preventing nosocomial infection. Failures in this role have resulted in critical reports in the media. We ascertained the current practices of New Zealand anaesthetists relating to infection control, by distributing a questionnaire to all 450 anaesthetists practising in New Zealand. Sixty-one percent responded.

Just over half the respondents had never read their hospital policy on infection control and over a third had never read the Australian and New Zealand College of Anaesthetists policy document on infection control. It was found that 3.4% rarely changed gloves if they became contaminated and 2.2% occasionally used the same syringe to administer drugs to more than one patient. The majority (86.3%) of respondents split one drug ampoule between more than one patient, 41.3% used multidose vials for more than one patient and 2.2% used pre-filled syringes for more than one patient. The majority complied with the College infection control policy for performing arterial cannulation (85.7%)), central venous cannulation (77.4%) and regional blockade (65.1%). Respondents ranked the overall risk of the anaesthetist contributing to the transmission of infectious agents on a scale from 0 to 10 (10=highest risk). The median response was 7, the modal response was 10 and interquartile range was 4 to 8.

There was a high level of awareness of the risks of contributing to cross-infection inherent in anaesthesia, most anaesthetists reporting that they followed recommended guidelines in this context. However, these data suggest more effort is required to promote compliance with appropriate guidelines.
Prediction of Successful Epidural Catheter Placement by a ‘Cold Test’
Authors: Sinha P. K. , Dubey P. K.
Published: January 2019

We tested the hypothesis that the patients’ feeling of cold sensation down the back during epidural drug administration through the epidural catheter was a reliable predictor of correct epidural catheter placement. In a prospective study of 80 patients, an epidural catheter was placed in the lumbar epidural space. During epidural drug injection, patients were asked to report feeling of the cold sensation in their back by pressing a bell. After 15 minutes, the patients were assessed for cold sensation in the thoracic to sacral dermatomes bilaterally and the dermatomal block recorded. Of 80 patients, three had inadvertent dural puncture. Seventy-two of 77 patients reported feeling cold sensation in their back during local anaesthetic injection, and all had successful epidural blockade. Of the five patients who did not report any cold sensation, three had failed epidural block and two successful epidural block. There were no false positive results. Of three patients who had inadvertent dural puncture and had normal saline 5 ml injected through the Tuohy needle, none reported cold sensation. The perception of cold sensation in the back during epidural administration of a test dose and/or subsequent full dose of local anaesthetic is useful in predicting successful epidural catheter placement.
Refractory Hypotension during Combined General and Epidural Anaesthesia in a Patient on Tricyclic Antidepressants
Authors: Takakura K. , Nagaya M. , Mori M. , Koga H. , Yoshitake S. , Noguchi T.
Published: January 2019

We report a case of refractory hypotension that occurred after epidural injection of local anaesthetic, in a patient who was receiving tricyclic antidepressant therapy and was under general anaesthesia. The patient failed to respond to repeated injections of appropriate doses of sympathomimetics, but did respond to high-dose catecholamine infusions. We suggest that epidural anaesthesia should be used with care when combined with general anaesthesia for patients on long-standing tricyclic antidepressant therapy. If refractory hypotension should occur in such patients, the use of direct-acting vasoconstrictors such as noradrenaline should be considered.
Perioperative Pulse Contour Cardiac Output Analysis in a Patient with Severe Cardiac Dysfunction
Authors: Jones D. , Story D. , Peyton P. , Bellomo R.
Published: January 2019

We describe a patient with severe left ventricular dysfunction simultaneously monitored with pulse contour cardiac output (PiCCO) analysis, a continuous cardiac output pulmonary artery catheter (continuous COPAC) and intraoperative transoesophageal echocardiography (TOE).

There was good agreement between cardiac output (CO) measurements obtained by the three techniques prior to cardiopulmonary bypass (CPB). Agreement of CO measurements following CPB was initially poor, but improved following recalibration of PiCCO.

PiCCO-derived global end-diastolic volume index (GEDVI) and cardiac function index (CFI), were assessed as markers of left ventricular preload and myocardial contractility, respectively. GEDVI correlated well with CO in the postoperative period.

CFI increased more than two -fold following coronary revascularization and milrinone administration, and there was also a temporal relationship between the CFI and the dose of milrinone in the first 24 hours of treatment.

Global end-diastolic volume and cardiac function index may be useful additional measures of left ventricular preload and myocardial contractility in patients with severe left ventricular dysfunction.
Outcomes following a Shortage of High Dependency Unit Beds for Surgical Patients
Authors: Mcilroy D. R. , Coleman B. D. , Myles P. S.
Published: January 2019

In an environment of resource rationing there are numerous patients who are unable to be admitted to a high-dependency unit (HDU) postoperatively despite the belief that this is the optimal discharge destination for them from the recovery room. It is unknown if this is associated with an increase in adverse outcomes. We performed an observational study, over a two-month period, comparing outcomes between patients who were admitted to HDU postoperatively and patients who, although an HDU bed was preferred, were discharged from the recovery room to the general ward due to an unavailability of HDU beds. Our primary outcome variable was hospital length-of-stay We found an almost twofold increase in hospital length-of-stay in the group of patients admitted to the HDU. ASA IV patients were more likely to be admitted to HDU. However, the increased length-of-stay in the HDU group persisted even after stratifying patients according to ASA status. There was no difference between groups in all other baseline demographic variables, including POSSUM score, which is used as a predictor of postoperative morbidity and mortality. We believe that the most likely explanation for our findings is that the baseline risk between groups is, in fact, subtly different. This is not detected by preoperative scoring systems. However, clinical judgement in the recovery room appears to select a group of patients for HDU admission who subsequently have a slower postoperative recovery, despite no measurable increase in complication rate. That there was no increase in adverse events in the group of patients unable to be admitted to HDU due to a lack of bed availability suggests that current clinical judgement in a resource-rationed environment is functioning adequately, but the study was not powered to detect such a difference.
Multiple Sites of Impingement of a Tracheal Tube as it is Advanced over a Fibreoptic Bronchoscope or Tracheal Tube Introducer in Anaesthetized, Paralysed Patients
Authors: Jackson A. H. , Orr B. , Yeo C. , Parker C. , Craven R. , Greenberg S. L.
Published: January 2019

Impingement of the tracheal tube on upper airway structures occurs commonly during advancement over a fibreoptic bronchoscope or introducer. In this descriptive study a fibrescope was used to assess the site and mechanism of tracheal tube impingement during advancement over a variety of fibreoptic bronchoscopes and introducers during orotracheal intubation in anaesthetized adults. The effect of the 90° counterclockwise rotation manoeuvre in overcoming impingement was also assessed. We recorded impingement at the right arytenoid, left arytenoid, epiglottis, interarytenoid tissue and the left pyriform fossa. Our study found a wider range of sites at which impingement may occur than in previous studies. We also found that when 90° counterclockwise rotation of the tip of the tracheal tube was achieved, the impingement was reliably overcome.
Tracheal Ulceration and Obstruction Associated with Flexible Bivona Tracheostomy Tubes
Authors: Tibballs J. , Robertson C. , Wall R.
Published: January 2019

An adjustable length tracheostomy tube, Bivona™, which assumes a curve on insertion, has a tendency to straighten itself in situ. The straightening force, measured electronically, was maximal (0.21 Newton) when a tube was bent 90 degrees. We observed particular clinical disadvantages of these tubes— that of tracheal ulceration (1 case), distortion of soft tracheal graft tissue (1 case) and airway obstruction when the tip embedded into the tracheal wall (1 case).
Effect of Heparin-bonded Central Venous Catheters on the Incidence of Catheter-related Thrombosis and Infection in Children and Adults
Authors: Long D. A. , Coulthard M. G.
Published: January 2019

The use of central venous catheters, while advantageous, is associated with a range of complications including thrombosis and infection. These complications can pose significant physical and financial costs to the patient and health care system. A critical appraisal of the two randomized controlled trials examining this topic in critically ill patients has shown that heparin-bonded central venous catheters significantly reduced the incidence of catheter-related thrombosis and infection in children and adults. These findings suggest that heparin-bonded central venous catheters should be considered for routine use in critically ill patients.
Vardenafil and Weaning from Inhaled Nitric Oxide: Effect on Pulmonary Hypertension in ARDS
Authors: Giacomini M. , Borotto E. , Bosottl L. , Denkewitz T. , Reali-Forster C. , Carlucci P. , Centanni S. , Mantero A. , Iapichino G.
Published: January 2019

We report a 66-year-old patient with refractory pulmonary hypertension secondary to ARDS who was being treated with inhaled nitric oxide. Enteral vardenafil (phosphodiesterase-5 inhibitor) was tried at two different doses (10 mg and 5 mg), in order to wean the patient from nitric oxide. The higher dose decreased pulmonary pressure but caused systemic hypotension and the drug was discontinued. Subsequently, a 5 mg dose of vardenafil decreased pulmonary pressure without hypotension. Pulmonary hypertension was controlled using vardenafil 10-15 mg divided in 2-3 daily doses. This therapy allowed nitric oxide withdrawal, weaning from mechanical ventilation and discharge from ICU.

Vardenafil acted in synergy with inhaled nitric oxide, permitted nitric oxide reduction and discontinuation and proved to be effective as a single, long-term treatment for pulmonary hypertension.
Isolated Ligamentous Cervical Spinal Injury in the Polytrauma Patient with a Head Injury
Authors: Weinberg L. , Hiew C. Y. , Brown D. J. , Lim E. J. , Hart G. K.
Published: January 2019

The evaluation of the cervical spine in the unconscious trauma patient is a difficult and controversial topic in trauma management. Conventional cervical clearance protocols consisting of plain radiology and computed tomography may not adequately detect unstable cervical ligament and disc injuries, even though a high-risk mechanism of injury has occurred. We present two cases where cervical clearance protocols, utilising plain X-rays and multislice computed tomography, failed to identify significant ligamentous spinal injuries. A delay in diagnosis or a missed spinal injury can lead to delays in treatment, thereby increasing the risk of neurological deterioration with the potential devastating sequela of quadriplegia. Therefore, in the unconscious trauma patient who, by definition, has sustained a high-risk mechanism injury, we routinely recommend the use of magnetic resonance imaging in addition to plain X-rays and computed tomography, to evaluate further discoligamentous status.
The training environment of junior anaesthetic registrars learning epidural labour analgesia in Australian teaching hospitals
Authors: Watterson L. M. , Hyde S. , Bajenov S. , Kennedy S. E.
Published: January 2019

Junior anaesthetic registrars perform epidural labour analgesia in many Australian hospitals, however data evaluating training and outcomes are scarce. We aimed to describe and evaluate training practices and environments provided for registrars who learn epidural labour analgesia in their first year of training. Twenty-nine registrars audited their epidurals, participated in semi-structured interviews and completed surveys for six months. The median (interquartile range) number of epidurals performed by each registrar was 17 (15–25). Fifty percent performed less than 20. Among 216 audited cases, complications were reported in 19% (dural puncture in 1.4%) and technical difficulties in 16%. Direct supervision was provided for a median (range) of 2.5 (6) epidurals per registrar and for a significantly higher proportion of epidurals performed in tertiary hospitals compared with district metropolitan and rural hospitals (35%, 6% and 22% respectively; P=0.001). Registrars felt senior staff had supportive attitudes, however the onus for initiating supervision appeared to be with the registrars and responses to survey items addressing role clarity and access to supervision showed wide variation. Only 33% of registrars agreed that they received adequate training before their first epidural and 67% reported workplace stress. None received formal assessments designed to ensure adequate supervision and competency. These results suggest that current training practices for these trainees are inadequate and could be improved by audit and structured workplace learning and assessment activities. We have demonstrated the potential value of measuring a range of training outcomes and environmental factors and have provided baseline data for future research.
Intraocular Pressure Changes Associated with Intubation with the Intubating Laryngeal Mask Airway Compared with Conventional Laryngoscopy
Authors: Bharti N. , Mohanty B. , Bithal P. K. , Dash M. , Dash H. H.
Published: January 2019

This open, prospective, randomised study was designed to evaluate the changes in intraocular pressure and haemodynamics after tracheal intubation using either the intubating laryngeal mask airway (ILMA) or direct laryngoscopy. Sixty adult patients, ASA physical status 1 or 2 with normal intraocular pressure were randomly allocated to one of the two techniques. Anaesthesia was induced with propofol followed by rocuronium. Tracheal intubation was performed using either the ILMA or Macintosh laryngoscope. Intraocular pressure, heart rate and blood pressure were measured immediately before and after tracheal intubation and then minutely for five minutes. In the laryngoscopy group there was a significant increase in intraocular pressure (from 7.2 ± 1.4 to 16.8 ± 5.3 mmHg, P <0.01), which did not return to pre-intubation levels within five minutes, and also in mean arterial pressure after tracheal intubation, which returned to baseline levels after five minutes. In the ILMA group there were no significant changes in intraocular pressure (from 7.6±1.8 to 10.4±2.8 mmHg, P >0.05) or mean arterial pressure after tracheal intubation. Time to successful intubation was longer with the ILMA, 56.8 ± 7.8 seconds, compared with the laryngoscopy group, 33±3.6 seconds (P <0.01). Mucosal trauma was more frequent with the ILMA (eight of 30) compared with the laryngoscopy group (three of 30) (P <0.01). The postoperative complications were comparable. In terms of minimising increases in intraocular pressure and blood pressure, we conclude that the ILMA has an advantage over direct laryngoscopy for tracheal intubation.
Fire-eater's lung
Authors: Boots R. J. , Weedon Z. J.
Published: January 2019

Hydrocarbon aspiration from fire-eating can result in severe necrotising pneumonia with complex cyst formation and large pleural effusions. Despite this, there is usually minimal persistent lung injury. We report the progress of two clinical cases, one of whom is the first reported case of citronella oil aspiration.
Risk Factors for Post-pneumonectomy Acute Lung Injury/Acute Respiratory Distress Syndrome in Primary Lung Cancer Patients
Authors: Jeon K. , Yoon J. W. , Suh G. Y. , Kim J. , Kim K. , Yang M. , Kim H. , Kwon O. J. , Shims Y. M.
Published: January 2019

Acute lung injury/acute respiratory distress syndrome (ALI / ARDS) is the most serious pulmonary complication after lung resection. This study investigated the incidence and outcome of patients with ALI / ARDS who required mechanical ventilation within one week of undergoing pneumonectomy for primary lung cancer and analysed the risk factors. We retrospectively reviewed the medical records of 146 patients who underwent pneumonectomy for primary lung cancer between May 2001 and April 2006. Preoperative, perioperative and postoperative clinical data were analysed. Post-pneumonectomy ALI / ARDS developed within the first postoperative week in 18 (12%) patients. Patients who developed ALI / ARDS had a longer hospital duration of stay (median [interquartile range], 26 [18 to 75] vs. 8 [7 to 11] days; P <0.001) and higher in-hospital mortality (12 [67%] vs. 0 [0%]; P <0.001). In an univariate analysis, post-pneumonectomy ALI / ARDS was associated with larger tidal volume (VT) and higher airway pressure (Paw) during one-lung ventilation (VT, 8.2 [7.5 to 9.0] vs. 7.7 [6.9 to 8.2] ml/kg predicted body weight, P=0.016; Paw, 28.9 [27.6 to 30.0] vs. 27.2 [25.6 to 28.5] cmH2O, P=0.001). VT during two-lung ventilation was also greater in patients who developed ALI / ARDS (P=0.014) than in those who did not, but Paw during two-lung ventilation did not differ (P=0.950). In a multiple logistic regression analysis, post-pneumonectomy ALI / ARDS was independently associated with a larger VT (OR 3.37 per 1 ml/kg predicted body weight increase; 95% confidence interval 1.65 to 6.86) and higher Paw (OR 2.32 per 1 cmH2O) increase; 95% confidence interval 1.46 to 3.67) during the period of one-lung ventilation. In conclusion, a large VT and high Paw during one-lung ventilation were associated with an increased risk of post-pneumonectomy ALI / ARDS in primary lung cancer patients.
APOE Genotype Affects Outcome in a Murine Model of Sepsis: Implications for a New Treatment Strategy
Authors: Wang H. , Christensen D. J. , Vitek M. P. , Sullivan P. M. , Laskowitz D. T.
Published: January 2019

In this study, we assessed whether apolipoprotein E (APOE) polymorphism affects inflammatory responses and mortality in the caecal ligation and puncture model of peritonitis. In addition, we determined the effects of APOE mimetic peptide administration in this sepsis model. Differences in survival between targeted replacement mice expressing the human APOE3 allele (APOE3TR) and the APOE4 allele (APOE4TR) mice were assessed. In a separate series of experiments, COG1410, an apoE-mimetic peptide, was administered intravenously at 12-hour intervals for 72 hours and compared to vehicle-treated control animals. End-points included mortality and serum levels of interleukin-1β, interleukin-6, interleukin-12 and tumour necrosis factor-alpha. Mice expressing the human APOE4 allele (n=16) demonstrated an increase in mortality following caecal ligation and puncture compared with APOE3TR mice (n=22; P=0.039). Administration of the apolipoprotein E mimetic COG1410 was well tolerated and APOE3TR mice treated with peptide (n=20) demonstrated a significant reduction in mortality compared with vehicle treated animals (n=20; P=0.007). A similar effect was also observed in APOE4TR animals, in which treatment with COG1410 was associated with reduced mortality compared with vehicle treatment (n=16 animals/group; P=0.027). COG1410 was also associated with a reduction in TNFα, interleukin-1β, interleukin-6 and interleukin-12 levels in both APOE3TR and APOE4TR (n=5 animals/group) assessed at 24 hours. Thus, administration of an apolipoprotein E-mimetic peptide is well tolerated, suppresses inflammatory responses, and improves mortality in a caecal ligation and puncture model of sepsis.
Comparison of Computer-integrated Patient-controlled Epidural Analgesia and Patient-controlled Epidural Analgesia with a Basal Infusion for Labour and Delivery
Authors: Sng B. L. , Sia A. T. H. , Lim Y. , Woo D. , Ocampo C.
Published: January 2019

Computer-integrated patient-controlled epidural analgesia (CIPCEA) is a novel epidural drug delivery system. It automatically adjusts the background infusion based on the individual parturient's need for analgesia as labour progresses.

In this randomised controlled trial, we compared the local anaesthetic consumption by parturients using either CIPCEA or patient-controlled epidural analgesia with a moderate basal infusion (PCEABI) of 5 ml/hour. We recruited 60 parturients after receiving ethics committee approval. Group CIPCEA (n=30) received a similar patient-controlled epidural analgesia regimen but the computer integration titrated the background infusion to 5, 10 or 15 ml/hour if the patient required respectively one, two or three demand boluses in the previous hour. The background infusion was decreased by 5 ml/hour if there was no demand in the previous hour. Group PCEABI received patient-controlled epidural analgesia with a basal infusion of 5 ml/hour. The sample size was calculated to show equivalence in local anaesthetic use.

The time-weighted consumption of local anaesthetic was similar in both groups (mean difference 0.3 mg/hour, 95% confidence interval: −1.8, 1.3, P=0.755). The CIPCEA group had higher maternal satisfaction scores: mean (SD) 94.8 (6.32) vs. 85.5 (9.41), P=0.0001. The CIPCEA group had a higher infusion rate during the second stage of labour (mean (SD) 7.0 (4.1) ml/hour vs. 4.5 (1.5) ml/hour, P= 0.008), but did not have a longer duration of this stage. There were no differences between the groups in obstetric or foetal outcomes or side-effect profiles.

The CIPCEA system has similar time-weighted, hourly consumption of local anaesthetic to PCEABI and may increase patient satisfaction.
Mechanism of Cardiac Preconditioning with Volatile Anaesthetics
Authors: Hu Z.-Y. , Liu J.
Published: January 2019

In recent years, there has been increased interest in the mechanisms involved in anaesthetic-induced cardioprotection. It is not thoroughly understood how volatile anaesthetics protect the myocardium from ischaemia or reperfusion injury, but the overall mechanism is likely to be multifactorial. This review examines the recent experimental and clinical research underlying the cellular and molecular mechanisms involved in anaesthetic-induced preconditioning.

A variety of intracellular signalling pathways have been implicated in the protective phenomenon. Ischaemic preconditioning and anaesthetic-induced preconditioning share similar molecular mechanisms, including activation of guanine nucleotide-binding proteins, triggering of second messenger pathways, activation of multiple kinases, mediation of nitric oxide formation and reactive oxygen species release, maintenance of intracellular and/or mitochondrial Ca2+ homeostasis and moderation of the opening of adenosine-triphosphate-sensitive potassium channels.

A more thorough understanding of the multiple signalling steps and the ultimate cytoprotective mechanisms underlying anaesthetic-induced preconditioning may lead to improvements in the management of ischaemia and/or reperfusion injury.
Bacterial Contamination in Solution Aspirated from Non-Sterile Packaged Fentanyl Ampoules: A Laboratory Study
Authors: Merriman S. , Paech M. J. , Keil A. D.
Published: January 2019

Iatrogenic meningitis is a rare complication of spinal anaesthesia. It is mandatory to use a technique which minimises the risk of introducing bacteria into the subarachnoid space. Currently available fentanyl ampoules require a careful drawing-up technique, as the outside of the ampoule is not sterile and there is potential to contaminate the contents in the drawing-up process. We designed a pilot laboratory study to determine the extent of bacterial contamination of fentanyl solutions drawn up from non-sterile packaged glass fentanyl ampoules using three different methods: aspirating through a 5 μm filter needle only, aspirating through a 5 μm filter needle after swabbing the neck of the ampoule with isopropyl alcohol and aspirating through an antibacterial filter in addition to the 5 μm filter needle. Ten anaesthetists used each method once, in randomised order, to draw up solution from three different fentanyl ampoules. Samples underwent bacterial culture in blood agar and enrichment broth for 48 hours. No significant growth was seen in any sample. This pilot study did not identify any bacterial contamination of fentanyl solution irrespective of which of the three methods for aspiration was used.
Sixteen Years of Severe Tiger Snake (Notechis) Envenoming in Perth, Western Australia
Authors: Scop J. , Little M. , Jelinek G. A. , Daly E E S.
Published: January 2019

We aimed to describe the characteristics, clinical course, management and outcome of patients presenting to Perth teaching hospitals after envenoming by Tiger snakes. We undertook a chart review from six Perth teaching hospitals over a 16 year period from 1990 to 2005. Data were collected by a trained investigator using a preformatted data abstraction tool. We included patients bitten in the appropriate geographical area, with defibrination coagulopathy and positive Venom Detection Kit result for Tiger snake or response to specific antivenom. Of 381 charts reviewed, 23 patients were envenomed by a Tiger snake. The mean age was 36 years, 83% were male and all were bitten on a limb. First aid was applied poorly and all patients were symptomatic on presentation. Six patients developed rhabdomyolysis, one renal failure, four clinical bleeding, three neurotoxicity, one non-fatal respiratory arrest and one fatal cardiac arrest. All patients received antivenom, 13 received adrenaline premedication, with two mild allergic reactions developing in non-premedicated patients. The average dose of antivenom was four ampoules. Mean hospital stay was 2.6 days. This is the largest series of Tiger snake envenoming reported in Australia. Only one patient of 23 (4%) died, despite all patients being significantly envenomed. With rapid antivenom treatment and modern emergency and intensive care management, most patients envenomed by Tiger snakes survive.
Potency of Mephentermine for Prevention of Post-spinal Hypotension
Authors: Mohta M. , Agarwal D. , Gupta L. K. , Sethi A. K. , Tyagi A.
Published: January 2019

This study was designed to determine the minimum effective dose (ED50) of mephentermine for prevention of post-spinal hypotension in women undergoing elective caesarean section. Dixon's up-down method of sequential allocation was used to determine the patient's dose of vasopressor drug. In our previous study, mephentermine appeared to be much more potent than ephedrine, so the present study was conducted using a lower initial dose and smaller dose interval for this vasopressor. Following administration of spinal anaesthesia, a prophylactic infusion of mephentermine was started with 5 mg infused over a period of 30 minutes as the initial dose and a dose interval of 1 mg. The ED50 of mephentermine of 3.7 mg (95% confidence interval 2.4 to 5.7 mg) was much less than that of ephedrine, as calculated in our previous study using the same methodology. Using these values gives a potency ratio of ephedrine to mephentermine of 1:6.8 (95% confidence interval 6.0 to 7.5).
The Role of Admission Surveillance Cultures in Patients Requiring Prolonged Mechanical Ventilation in the Intensive Care Unit
Authors: Viviani M. , van Saene H. K. F. , Pisa F. , Lucangelo U. , Silvestri L. , Momesso E. , Berlot G.
Published: January 2019

We undertook a prospective observational cohort study in intensive care unit (ICU) patients requiring mechanical ventilation for four days or more to evaluate normal and abnormal bacterial carriage on admission detected by surveillance cultures of throat and rectum. We assessed the importance of surveillance and diagnostic cultures for the early detection of resistance to third generation cephalosporins employed as the parenteral component of the selective decontamination of the digestive tract. Finally, we sought the risk factors of abnormal carriage on admission to the ICU. During the 58-month study 621 patients were included: 186 patients (30%) carried abnormal flora including methicillin-resistant Staphylococcus aureus (MRSA) and aerobic Gram negative bacilli (AGNB) on admission to the ICU. Both MRSA and AGNB carriers were more commonly present in the hospital group of patients than in patients referred from the community (P <0.001), although overgrowth was equally present both in community and in hospital patients. The incidence of infections during ICU stay was higher in abnormal (n=120, 64.5%) than in normal carriers (n=185, 42.5%) (P <0.0001), with an odds ratio of 2.46 (95% confidence interval 1.72 to 3.51). Third generation cephalosporins covered ICU admission flora in 482 (78%) of the studied population. AGNB resistant to cephalosporins and MRSA were detected in surveillance cultures of 139 patients (22%), while the same resistant micro-organisms were identified only in 49 diagnostic samples (7.9%). Parenteral cephalosporins were modified in patients with abnormal flora (P <0.0001). One hundred and ninety-six patients received antibiotics before admission to the ICU and 42% carried AGNB resistant to cephalosporins. Previous antibiotic use was the only risk factor for abnormal carriage in the multivariate analysis (OR 3.5; 95% confidence interval 2.1 to 5.8). The knowledge of carriage on admission using surveillance cultures may help intensivists to identify patients with abnormal carriage on admission and resistant bacterial strains at an early stage even when diagnostic samples are negative. Third generation cephalosporins covered admission flora in about 80% of the enrolled population and were modified in patients with abnormal flora who received antibiotic therapy before ICU admission. Our finding of overgrowth present on admission may justify the immediate administration of enteral antimicrobials.
Tongue Swelling Complicating Management of a Ventilated Patient with Acute Respiratory Distress Syndrome Secondary to Novel Influenza A (H1N1)
Authors: Scott A. , More R. , Freebairn R. C.
Published: January 2019

The recently emerged novel influenza A H1N1 virus continues to spread globally. The use of oseltamivir for treatment and prophylaxis of infection is recommended and its use has climbed steeply although there is little data available on its benefit in critically unwell patients with H1N1 influenza. A rare side-effect of oseltamivir treatment reported in post-marketing surveillance is tongue and lip swelling/angioedema. This case report describes the management of a critically ill ventilated patient with severe acute respiratory distress syndrome who developed clinically significant tongue and lip swelling during treatment with oseltamivir.
Total Spinal following Labour Epidural Analgesia Managed with Non-Invasive Ventilation
Authors: Guterres A. P. , Newman M. J.
Published: January 2019

A 30-year-old woman developed total spinal anaesthesia during establishment of labour analgesia via an epidural catheter. The subsequent respiratory failure was successfully managed with non-invasive ventilation. This report describes the use of non-invasive ventilation in the parturient and the process of managing the parturient safely in an appropriately monitored environment. This case displays the potential benefit of this technique in the setting of a total spinal block in preventing the need for intubation and ventilation (and subsequent emergency caesarean section) and providing adequate ventilatory function until the block subsided adequately.
A Prospective Comparison between Written Examination and Either Simulation-Based or Oral Viva Examination of Intensive Care Trainees’ Procedural Skills
Authors: Nunnink L. , Venkatesh B. , Krishnan A. , Vidhani K. , Udy A.
Published: January 2019

We compared results of written assessment of intensive care trainees’ procedural skills with results obtained from one of two live assessment formats for the purposes of assessing the concurrent validity of the different test methods. Forty-five Australasian senior trainees in intensive care medicine completed a written test relating to a procedural skill, as well as either a simulation format or oral viva assessment on the same procedural skill.

We analysed correlation between written exam results and results obtained from simulation format or oral viva assessment. For those who completed the simulation format examination, we also maintained a narrative of actions and identified critical errors.

There was limited correlation between written exam results and live (simulation or viva) procedure station results (r=0.31). Correlation with written exam results was very low for simulation format assessments (r=0.08) but moderate for oral viva format assessment (r=0.58). Participants who passed a written exam based on management of a blocked tracheostomy scenario performed a number of dangerous errors when managing a simulated patient in that scenario.

The lack of correlation between exam formats supports multi-modal assessment, as currently it is not known which format best represents workplace performance. Correlation between written and oral viva results may indicate redundancy between those test formats, whereas limited correlation between simulation and written exams may support the use of both formats as part of an integrated assessment strategy. We hypothesise that identification of critical candidate errors in a simulation format exam that were not exposed in a written exam may indicate better predictive validity for simulation format examination of procedural skills.
Comparison of Automated Intermittent Low Volume Bolus with Continuous Infusion for Labour Epidural Analgesia
Authors: Lim Y. , Chakravarty S. , Ocampo C. E. , Sia A. T.
Published: January 2019

Delivery of local anaesthetics via automated intermittent bolus has been shown to improve epidural analgesia compared to delivery via continuous epidural infusion. However, the optimal bolus volume has not been investigated. This randomised, double-blind study compared the analgesic efficacy of automated intermittent bolus (volume 2.5 ml every 15 minutes) with that of a continuous epidural infusion (10 ml/hour) for the maintenance of labour epidural analgesia, to determine whether the advantages previously demonstrated for automated intermittent bolus over continuous epidural infusion are retained at this low bolus volume. With the approval of the Hospital Ethics Committee, we recruited 50 parturients who received combined spinal epidural analgesia with intrathecal ropivacaine 2 mg and fentanyl 15 μg. For epidural maintenance, participants were randomised to either the automated intermittent bolus group (2.5 ml automated intermittent epidural boluses of ropivacaine 0.1% plus fentanyl 2 μg/ml delivered over a two-minute period every 15 minutes) or the continuous epidural infusion group (continuous epidural infusion of ropivacaine 0.1% plus fentanyl 2 μg/ml at 10 ml/hour). The primary study outcome was the incidence of pain during labour that required management with supplemental epidural analgesia. There were no significant differences between the two regimens in terms of breakthrough pain (automated intermittent bolus 36% [9/25] vs continuous epidural infusion 32% [8/25], P=0.77). At the doses used in this study, maintenance of labour analgesia using automated intermittent bolus at a bolus volume of 2.5 ml every 15 minutes does not decrease the incidence of breakthrough pain or improve analgesic efficacy compared to continuous epidural infusion.