bluuebunny/crossref_metadata_2025 huggingface dataset:
Anaesthetic Implications of the Changing Management of Patients with Mucopolysaccharidosis
Authors: Hack H. A. , Walker R. W. M. , Gardiner P.
Published: January 2019

The mucopolysaccharidoses are a group of inherited metabolic disorders that are renowned for presenting clinical problems, particularly related to cardiac, airway, and skeletal abnormalities, in children during anaesthesia. The changing clinical management of the mucopolysaccharidoses can be described in three phases. An initial phase of accumulation and dissemination of knowledge about the management of this rare disease with a growing recognition that untreated Hurler syndrome and more severe forms of other phenotypes such as Hunter syndrome and Maroteaux–Lamy syndrome were associated with severe complications under anaesthesia. This was followed by a second phase reflecting the beneficial results of new treatments such as haemopoietic stem cell transplantation and enzyme replacement therapy. Early and successful transplantation has dramatically improved long-term outcome and reduced anaesthetic complications in children with Hurler syndrome. Enzyme replacement therapy is available for many forms of mucopolysaccharidosis. If commenced at an early age improvement in many organ systems may be observed with an improved quality of life. However, these current treatment regimens do not appear to improve neurocognitive dysfunction, or cardiac valvular or skeletal abnormalities. We are now entering a third phase where the partial benefits of these treatment regimens are resulting in an increasing number of older patients with partially corrected abnormalities, including difficult airways, presenting for ongoing treatment to a new and potentially unsuspecting group of clinicians. Major airway abnormalities may be encountered and current adult guidelines may need to be adapted. A multidisciplinary team approach involving paediatric and adult anaesthetists is recommended to optimise future management.
Bow-Tie Diagrams for Risk Management in Anaesthesia
Authors: Culwick M. D. , Merry A. F. , Clarke D. M. , Taraporewalla K. J. , Gibbs N. M.
Published: January 2019

Bow-tie analysis is a risk analysis and management tool that has been readily adopted into routine practice in many high reliability industries such as engineering, aviation and emergency services. However, it has received little exposure so far in healthcare. Nevertheless, its simplicity, versatility, and pictorial display may have benefits for the analysis of a range of healthcare risks, including complex and multiple risks and their interactions. Bow-tie diagrams are a combination of a fault tree and an event tree, which when combined take the shape of a bow tie. Central to bow-tie methodology is the concept of an undesired or ‘Top Event’, which occurs if a hazard progresses past all prevention controls. Top Events may also occasionally occur idiosyncratically. Irrespective of the cause of a Top Event, mitigation and recovery controls may influence the outcome. Hence the relationship of hazard to outcome can be viewed in one diagram along with possible causal sequences or accident trajectories. Potential uses for bow-tie diagrams in anaesthesia risk management include improved understanding of anaesthesia hazards and risks, pre-emptive identification of absent or inadequate hazard controls, investigation of clinical incidents, teaching anaesthesia risk management, and demonstrating risk management strategies to third parties when required.
Comparison of Kinemyography and Electromyography during Spontaneous Recovery from Non-Depolarising Neuromuscular Blockade
Authors: Khandkar C. , Liang S. , Phillips S. , Lee C. Y. , Stewart P. A.
Published: January 2019

This study compared two commercially available quantitative neuromuscular function monitoring techniques, kinemyography (KMG) and electromyography (EMG), to assess whether KMG could be used interchangeably with EMG to exclude residual neuromuscular blockade (RNMB). Train-of-four (TOF) ratios were recorded every 20 seconds using KMG at the adductor pollicis and EMG at the first dorsal interosseous of the same hand during spontaneous recovery from shallow neuromuscular blockade. TOF ratios were compared using Bland–Altman analysis for repeated measurements. The precision of each device was assessed by the repeatability coefficient. Agreement between devices was assessed by the bias and limits of agreement. Clinically acceptable agreement was defined as a bias <0.025 within limits of agreement ±0.05. We recorded 629 sets of TOF ratios from 23 patients. The repeatability coefficient for KMG was 0.05 (95% confidence interval [CI] 0.05 to 0.06) and for EMG 0.10 (95% CI 0.10 to 0.11). Overall, the bias of KMG TOF ratios against EMG TOF ratios was 0.11 (95% CI 0.10 to 0.12), with limits of agreement −0.11 to 0.32. In the 0.80 to 0.99 TOF range, the bias was 0.08 (95% CI 0.06 to 0.09) and the limits of agreement were-0.12 to 0.27. Overall, TOF ratios measured by KMG were on average 0.11 higher than EMG. In the 0.80 to 0.99 TOF range, KMG TOF ratios were 0.08 higher. EMG and KMG are not interchangeable because the bias is large and the limits of agreement are wide. Thus a maximum TOF ratio of 1.0 on KMG may not exclude RNMB.
Sequencing of Genes Involved in the Movement of Calcium across Human Skeletal Muscle Sarcoplasmic Reticulum: Continuing the Search for Genes Associated with Malignant Hyperthermia
Authors: Bjorksten A. R. , Gillies R. L. , Hockey B. M. , Du Sart D.
Published: January 2019

The genetic basis of malignant hyperthermia (MH) is not fully characterised and likely involves more than just the currently classified mutations in the gene encoding the skeletal muscle ryanodine receptor ( RYR1) and the gene encoding the α1 subunit of the dihydropyridine receptor ( CACNA1S). In this paper we sequence other genes involved in calcium trafficking within skeletal muscle in patients with positive in vitro contracture tests, searching for alternative genes associated with MH. We identified four rare variants in four different genes ( CACNB1, CASQ1, SERCA1 and CASQ2) encoding proteins involved in calcium handling in skeletal muscle in a cohort of 30 Australian MH susceptible probands in whom prior complete sequencing of RYR1 and CACNA1S had yielded no rare variants. These four variants have very low minor allele frequencies and while it is tempting to speculate that they have a role in MH, they remain at present variants of unknown significance. Nevertheless they provide the basis for a new set of functional studies, which may indeed identify novel players in MH.
Advances in the Diagnosis of Shock, Its Assessment and Resuscitation during the Great War
Authors: Bullingham A. G. P.
Published: January 2019

The Great War of 1914–1918 ushered in a new era of technology on the battlefield resulting In casualties on an unprecedented scale. There had been progress In many related areas of medicine before the outbreak of hostilities but these had not been applied or fully developed In clinical practice. This is particularly true for the management of haemorrhagic shock and resuscitation. This article discusses the history and development of medical treatment of shock and trauma patients during the conflict.
The etymology and Use of the Word ‘Anaesthesia’: Oliver Wendell Holmes' Letter to W. T. G. Morton
Authors: Haridas R. P.
Published: January 2019

Two published versions of a letter in which Oliver Wendell Holmes, MD, recommended the name anaesthesia were identified from publications supportive of the claims of W. T. G. Morton. The earliest known publication of Holmes' letter is in a pamphlet published by Edward Warren in May-June 1847. Another version of the letter was published 12 years later in Nathan P. Rice's biography of Morton. Holmes' letter to Morton was probably lost when a substantial part of a collection of Morton's papers was damaged during storage. There are no reported copies of Holmes' letter. The currently available Information does not provide any assistance in determining the correct form of Holmes' letter.
Apnoeic Oxygenation during Intubation: A Systematic Review and Meta-analysis
Authors: White L. D. , Melhuish T. M. , White L. K. , Wallace L. A.
Published: January 2019

Apnoeic oxygenation during intubation is used to prevent desaturation during intubation. The aim of this review was to assess whether apnoeic oxygenation during endotracheal intubation reduced the incidence of hypoxaemia. Five major databases were systematically searched for all relevant studies published up to May 2016. All study designs with a control group and a group receiving apnoeic oxygenation were included in this review. These studies were then assessed for level of evidence and risk of bias. The data were then analysed using a meta-analysis. Eleven studies (six high quality randomised controlled trials, four low quality level two studies and one low quality level three study) were found. In the meta-analysis there was strong evidence for benefit of apnoeic oxygenation in terms of improved SpO2 in elective surgical patients, obese patients and those undergoing emergency intubation without respiratory failure. However, no significant benefit was found in patients with respiratory failure. This is the first meta-analysis to be performed on apnoeic oxygenation during intubation. Apnoeic oxygenation provides significant benefit in terms of improving SpO2 for the majority of intubations, although there appears to be no benefit in patients whose indication for intubation is respiratory failure. Apnoeic oxygenation ought to be considered for integration into intubation protocols.
The Addition of Tick-boxes Related to Tobacco Cessation Improves Smoking-related Documentation in the Anaesthesia Chart
Authors: Webb A. , Wilson A. C.
Published: January 2019

The Australian and New Zealand College of Anaesthetists (ANZCA) ‘Guidelines on Smoking as Related to the Perioperative Period (PS12)’ recommends that anaesthetists should always ask about smoking, advise quitting and refer patients to their general practitioner (GP) or a telephone quit-line for quit support. In this study we evaluated the effect of adding tick-boxes for ‘quit advice given’ and ‘referral to GP/Quitline’ to anaesthesia charts of elective surgical patients to assess whether this intervention changed documentation of compliance with the ANZCA guideline. The anaesthesia charts of all smokers were reviewed for evidence of asking, advising and referring, over two three-month periods (n=999) separated by the intervention of placing a sticker to modify the preoperative charts of all elective patients which added tick-box prompts of advice and referral. No educational campaigns occurred to encourage tick-box use. No changes were made to non-elective charts. Evidence of advice to quit was 1.8% prior to, rising to 18.7% after, the intervention ( P <0.001), while evidence of referral rose from 0.9% to 5.8%. There was negligible change in non-elective patients, who did not receive the intervention. The addition of tick-boxes improved the documentation of smoking cessation support, but as documented rates of quit support remained relatively low even after the intervention, tick-boxes alone cannot be relied upon to improve alignment of care with the ANZCA guidelines.
Prognosis of Patients with Rheumatic Diseases Admitted to Intensive Care
Authors: Beil M. , Sviri S. , de la Guardia V. , Stav I. , Ben-Chetrit E. , van Heerden P. V.
Published: January 2019

Variable mortality rates have been reported for patients with rheumatic diseases admitted to an intensive care unit (ICU). Due to the absence of appropriate control groups in previous studies, it is not known whether the presence of a rheumatic disease constitutes a risk factor. Moreover, the accuracy of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score for predicting outcome in this group of patients has been questioned. The primary goal of this study was to compare outcome of patients with rheumatic diseases admitted to a medical ICU to those of controls. The records of all patients admitted between 1 April 2003 and 30 June 2014 (n=4020) were screened for the presence of a rheumatic disease during admission (n=138). The diagnosis of a rheumatic disease was by standard criteria for these conditions. An age- and gender-matched control group of patients without a rheumatic disease was extracted from the patient population in the database during the same period (n=831). Mortality in ICU, in hospital and after 180 days did not differ significantly between patients with and without rheumatic diseases. There was no difference in the performance of the APACHE II score for predicting outcome in patients with rheumatic diseases and controls. This score, as well as a requirement for the use of inotropes or vasopressors, accurately predicted hospital mortality in the group of patients with rheumatic diseases. In conclusion, patients with a rheumatic condition admitted to intensive care do not do significantly worse than patients without such a disease.
Elective Use of Veno-venous Extracorporeal Membrane Oxygenation and High-flow Nasal Oxygen for Resection of Subtotal Malignant Distal Airway Obstruction
Authors: Fung R. K. F. , Stellios J. , Bannon P. G. , Ananda A. , Forrest P.
Published: January 2019

We describe the use of peripheral veno-venous extracorporeal membrane oxygenation (VV ECMO) and high-flow nasal oxygen as procedural support in a patient undergoing debulking of a malignant tumour of the lower airway. Due to the significant risk of complete airway obstruction upon induction of anaesthesia, ECMO was established while the patient was awake, and was maintained without systemic anticoagulation to minimise the risk of intraoperative bleeding. This case illustrates that ECMO support with high-flow nasal oxygen can be considered as part of the algorithm for airway management during surgery for subtotal lower airway obstruction, as it may be the only viable option for maintaining adequate gas exchange.
The Expanding Role of Extracorporeal Membrane Oxygenation Retrieval Services in Australia
Authors: Edelman J. J. B. , Wilson M. K. , Vallely M. P. , Bannon P. G. , McKay G. , Robertson S. J. , Hislop R. , Wong C. , Cartwright B. L. , Forrest P. , Torzillo P. J.
Published: January 2019

Herein we detail the cases of three patients transferred on veno-arterial extracorporeal membrane oxygenation (VA ECMO) from a tertiary referral hospital to an ECMO centre. We highlight the benefits of such a transfer and offer this as a model of care for unwell patients likely to require a prolonged period of ECMO support.
The Effect of a Perioperative Ketamine Infusion on the Incidence of Chronic Postsurgical Pain—A Pilot Study
Authors: Peyton P. J. , Wu C. , Jacobson T. , Hogg M. , Zia F. , Leslie K.
Published: January 2019

Chronic postsurgical pain (CPSP) is a common and debilitating complication of major surgery. We undertook a pilot study at three hospitals to assess the feasibility of a proposed large multicentre placebo-controlled randomised trial of intravenous perioperative ketamine to reduce the incidence of CPSP. Ketamine, 0.5 mg/kg pre-incision, 0.25 mg/kg/hour intraoperatively and 0.1 mg/kg/hour for 24 hours, or placebo, was administered to 80 patients, recruited over a 15-month period, undergoing abdominal or thoracic surgery under general anaesthesia. The primary endpoint was CPSP in the area of the surgery reported at six-month telephone follow-up using a structured questionnaire. Fourteen patients (17.5%) reported CPSP (relative risk [95% confidence interval] if received ketamine 1.18 [0.70 to 1.98], P=0.56). Four patients in the treatment group and three in the control group reported ongoing analgesic use to treat CPSP and two patients in each group reported their worst pain in the previous 24 hours at ≥3/10 at six months. There were no significant differences in adverse event rates, quality of recovery scores, or cumulative morphine equivalents consumption in the first 72 hours. Numeric Rating Scale pain scores (median [interquartile range]) for average pain in the previous 24 hours among those patients reporting CPSP were 17.5 [0 to 40] /100 with no difference between treatment groups. A large (n=4,000 to 5,000) adequately powered multicentre trial is feasible using this population and methodology.
Proceedings of the 12th International Conference on Rapid Response Systems and Medical Emergency Teams
Authors: Jones D. , Holmes J. , Currey J. , Fugaccia E. , Psirides A. J. , Singh M. Y. , Fennessy G. J. , Hillman K. , Pilcher D. V. , Bellomo R. , DeVita M.
Published: January 2019

Rapid Response Teams (RRTs) have been introduced into hospitals worldwide in an effort to improve the outcomes of deteriorating hospitalised patients. Recently, there has been increased awareness of the need to develop systems other than RRTs for deteriorating patients. In May 2016, the 12th International Conference on Rapid Response Systems and Medical Emergency Teams was held in Melbourne. This represented a collaboration between the newly constituted International Society for Rapid Response Systems (iSRRS) and the Australian and New Zealand Intensive Care Society. The conference program included broad ranging presentations related to general clinical deterioration in the acute care setting, as well as deterioration in the emergency department, during pregnancy, in the paediatric setting, and deterioration in mental health status. This article briefly summarises the key features of the conference, links to presentations, and the 18 abstracts of the accepted free papers.
Australian and New Zealand Anaesthetic Allergy Group Perioperative Anaphylaxis Investigation Guidelines
Authors: Scolaro R. J. , Crilly H. M. , Maycock E. J. , McAleer P. T. , Nicholls K. A. , Rose M. A. , The R. I. H.
Published: January 2019

These guidelines are a consensus document developed by a working party of the Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) to provide an approach to the investigation of perioperative anaphylaxis. They focus primarily on the use of skin testing as it is the investigation with the greatest clinical utility for the identification of the likely causative agent and potentially safer alternatives. The practicalities and process of skin testing, its limitations, and the place of other tests are discussed. These guidelines also address the roles of graded challenge and in vitro testing. The implications of anaphylaxis associated with neuromuscular blocking agents, beta-lactam antibiotics, local anaesthetic agents and chlorhexidine are discussed. Evidence for the recommendations is derived from literature searches using the words skin test, allergy, anaphylaxis, anaesthesia, and each of the individual agents listed in these guidelines. The individual articles were then reviewed for suitability for inclusion in these guidelines. Where evidence was not strong, as is the situation for many perioperative agents, expert consensus from the ANZAAG working party was used. These guidelines are intended for use by specialists involved in the investigation of perioperative allergy. They have been approved following peer review by members of ANZAAG and are available on the ANZAAG website: http://www.anzaag.com/anaphylaxis-management/testing-guidelines.pdf .
In Vitro Evaluation of the Effect of Haemodilution with Dextran 40 on Coagulation Profile as Measured by Thromboelastometry and Multiple Electrode Aggregometry
Authors: Kam P. C. A. , Liou J. P. C. , Yang K. X. F.
Published: January 2019

We evaluated the effects of haemodilution with either dextran 40 or 0.9% normal saline on coagulation in vitro using rotational thromboelastometry (ROTEM®, Pentapharm Co., Munich, Germany) and multiple electrode aggregometry (Multiplate® Platelet Function Analyser, Dynabyte, Munich, Germany). Venous blood samples obtained from 20 healthy volunteers were diluted in vitro with dextran 40 or normal saline by 5%, 10% and 15%. Fibrinogen concentration, ROTEM-EXTEM® (screening test for the extrinsic coagulation pathway), FIBTEM® (an EXTEM-based assay of the fibrin component of clot) parameters including coagulation time, clot formation time, alpha angle, maximum clot firmness and lysis index were measured in the undiluted sample and at each level of haemodilution. Dextran 40 at 15% haemodilution significantly prolonged coagulation time, clot formation time and significantly decreased the alpha angle and maximal clot firmness (EXTEM amplitude at five minutes [A5] and ten minutes [A10]) compared with normal saline. The FIBTEM assay (maximal clot firmness and FIBTEM A5 and A10) showed a marked decrease in maximal clot firmness at all dilutions suggesting impaired fibrinogen activity and a risk of bleeding. Multiple electrode aggregometry did not demonstrate any platelet dysfunction. Haemodilution with dextran 40 causes significant impairment in clot formation and strength compared to saline haemodilution and undiluted blood. At the levels of in vitro haemodilution designed to reflect the clinical use of dextran infusions, no significant fibrinolysis or platelet inhibition was observed.
The Effect of a Surgery-Specific Cardiac Output–Guided Haemodynamic Algorithm on Outcomes in Patients Undergoing Pancreaticoduodenectomy in a High-Volume Centre: A Retrospective Comparative Study
Authors: Weinberg L. , Banting J. , Churilov L. , McLeod R. L. , Fernandes K. , Chao I. , Ho T. , Ianno D. , Liang V. , Muralidharan V. , Christophi C. , Nikfarjam M.
Published: January 2019

In this retrospective observational study performed in a high-volume hepatobiliary–pancreatic unit, we evaluated the effect of a surgery-specific goal-directed therapy (GDT) physiologic algorithm on complications and length of hospital stay. We compared patients who underwent pancreaticoduodenectomy with either a standardised Enhanced Recovery After Surgery program (usual care group), or a standardised Enhanced Recovery After Surgery program in combination with a surgery-specific cardiac output–guided algorithm (GDT group). We included 145 consecutive patients: 47 in the GDT group and 98 in the usual care group. Multivariable associations between GDT and lengths of stay and complications were investigated using negative binomial regression. Postoperative complications were common and occurred at similar frequencies amongst the GDT and usual care groups: 64% versus 68% respectively, P=0.71; odds ratio 0.82; (95% confidence interval 0.39–1.70). There were fewer cardiorespiratory complications in the GDT group. Median (interquartile range) length of hospital stay was ten days (8.0–14.0) in the GDT group compared to 13 days (8.8–21.3) in the usual care group, P=0.01. Median (interquartile range) total intraoperative fluid was 3,000 ml (2,050–4,175) in the GDT group compared to 4,500 ml (3,275–5,325) in the usual care group, P <0.0001; but by day one, the median (interquartile range) fluid balance was similar (1,198 ml [700–1,729] in the GDT group versus 977 ml [419–2,044] in the usual care group, P=0.96). Use of vasoactive medications was higher in the GDT group. In our patients undergoing pancreaticoduodenectomy, GDT was associated with restrictive intraoperative fluid intervention, fewer cardiorespiratory complications and a shorter hospital length of stay compared to usual care. However, we could not exclude an influence of surgical caseload, which we have previously found to be an important variable. We also could not relate the increased hospital length of stay to cardiorespiratory complications in individual patients. Therefore, these observational retrospective findings would require confirmation in a prospective randomised study.
Effect of Hypocaloric Normoprotein Or Trophic Feeding versus Target Full Feeding on Patient Outcomes in Critically Ill Adults: A Systematic Review
Authors: Phan K. A. , Dux C. M. , Osland E. J. , Reade M. C.
Published: January 2019

Uncertainty surrounds the optimal approach to feeding the critically ill, with increasing interest in the concept of intentional underfeeding to reduce metabolic stress while maintaining gut integrity. Conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, this systematic review evaluates clinical outcomes reported in studies comparing hypocaloric normonitrogenous or trophic feeding (collectively ‘intentional underfeeding’) to target full energy feeding administered via enteral nutrition to adult critically ill patients. Electronic databases including PubMed, CINAHL, EMBASE and CENTRAL were searched up to September 2017 for trials evaluating intentional underfeeding versus targeted energy feeding interventions on clinical outcomes (mortality, length of stay, duration of ventilation, infective complications, feeding intolerance and glycaemic control) among critically ill adult patients. Bias of included studies was assessed using the Cochrane risk of bias tool. Of the 595 articles identified, seven studies (six randomised controlled trials, one non-randomised trial) met the inclusion criteria, representing 2,684 patients (hypocaloric normonitrogenous n=668; trophic n=681; full energy feeding n=1335). Across the studies, there was considerable heterogeneity in study methodology, population, feeding strategy and outcomes and their timepoints. We observed no evidence that intentional underfeeding, when compared to targeting full energy feeding, reduced mortality or duration of ventilation or length of stay. However, limited trial evidence is available on the impact of intentional underfeeding on post-discharge functional and quality of life outcomes.
Assessment of the Reliability of Intubation and Ease of Use of the Cook Staged Extubation Set—An Observational Study
Authors: Furyk C. , Walsh M. L. , Kaliaperumal I. , Bentley S. , Hattingh C.
Published: January 2019

The Staged Extubation Set has recently been introduced by Cook Medical for the management of difficult airway patients who potentially require reintubation; however, its reliability for intubation and ease of use is not reported in the literature. The set contains a wire and reintubation catheter with a central lumen for the wire and oxygenation if required. Reintubation is by a two-stage Seldinger-like technique. After induction of general anaesthesia, 23 low-risk elective surgical patients had the Staged Extubation Wire from the Cook set inserted into their trachea under direct laryngoscopy. The intubation was subsequently completed using the rest of the Staged Extubation Set as designed. Difficult intubation was simulated by intentionally decreasing the laryngeal view. Simulated reintubation failed in 8.3% and significant technical difficulty in simulated reintubation was noted in another 17.3% of intubation sequences. The latter represent probable failures in a clinical difficult reintubation setting. The mean time taken to intubate was 109 seconds. Using the Cook Staged Extubation Set may be inferior to using an airway exchange catheter for reintubation.
Evidence of Malignant Hyperthermia in Patients Administered Triggering Agents before Malignant Hyperthermia Susceptibility Identified: Missed Opportunities Prior to Diagnosis
Authors: Chan T. Y. , Bulger T. F. , Stowell K. M. , Gillies R. L. , Langton E. E. , Street N. E. , Pollock N. A.
Published: January 2019

Malignant hyperthermia (MH) is a hypermetabolic disorder of skeletal muscle triggered almost exclusively by potent inhalational agents and suxamethonium. Signs of an MH reaction are non-specific and may be confused with the presentation of other problems such as sepsis and overheating of a patient. A high index of suspicion is needed to be aware of an early presentation of MH. Nine patients are presented who showed abnormal signs with an earlier anaesthetic where the possible diagnosis of an MH reaction was missed. These patients either presented later with an MH reaction, confirmed by DNA analysis and in some cases in vitro contracture testing, or were diagnosed by the identification of a causative mutation confirming MH susceptibility. The MH clinical grading scale is helpful in determining the likelihood that clinical indicators indicate a possible MH reaction. Masseter muscle rigidity is a known sign of MH, confirmed in this report by positive in vitro contracture testing and DNA analysis. Several uncommon muscle disorders have a high association with MH, and postoperative myalgia unrelated to suxamethonium can be a sign which is associated with MH. These reports emphasise the importance of a thorough family history (as the MH status was known by the family in four patients), a high index of suspicion for MH, and documentation of the possibility of MH susceptibility in the anaesthesia record.
The Effectiveness of Regional Anaesthesia before and after the Introduction of a Dedicated Regional Anaesthesia Service Incorporating a Block Room
Authors: Chin A. , Heywood L. , Iu P. , Pelecanos A. M. , Barrington M. J.
Published: January 2019

Dedicated regional anaesthesia services incorporating block rooms and/or block teams may facilitate theatre efficiency and improve training in regional anaesthesia. Currently, it is unknown if a dedicated regional anaesthesia service improves the effectiveness of regional anaesthesia. In November 2013, the Royal Brisbane and Women's Hospital established a dedicated regional anaesthesia service comprising a block team and a block room. Pre-intervention (conventional model of care) registry data was retrospectively compared with post-intervention (dedicated regional anaesthesia service) audit data, with regard to pain and opioid requirement in the post-anaesthesia care unit (PACU). The primary outcome was inadequate analgesia, defined as a numerical rating scale (NRS; 0, no pain; 10, worst pain imaginable) for pain >5 in the PACU. Pre- and post-intervention, 43.7% and 27.7% of patients respectively reported a NRS >5 (P <0.001). A difference in the type of blocks and surgery performed may have accounted for the improved outcome seen post-intervention. After adjustment for American Society of Anesthesiologists physical status, block type and surgery type, the odds ratio of having inadequate analgesia (NRS >5) was 0.54 (95% confidence interval 0.39 to 0.76) for post-intervention compared to pre-intervention. Secondary outcomes examined pre- and post-intervention were the absence of pain (39.3% and 55.1% of patients, respectively, P <0.001), systemic opioid analgesia requirement (48.6% and 30.5% of patients respectively, P <0.001) and median maximum NRS (4 [interquartile range (IQR) 0 to 8] and 0 [IQR 0 to 6] respectively, P <0.001). A dedicated regional anaesthesia service was associated with improved effectiveness of regional anaesthesia.
Transoesophageal Echocardiography in the Intensive Care Unit
Authors: McLean A. S.
Published: January 2019

The role of transoesophageal echocardiography (TOE) in a general intensive care unit was examined by reviewing all studies performed in a major metropolitan hospital over a two-year period. TOE was performed on 53 patients where transthoracic studies were inadequate, the indications being cardiac source of embolus (13/53), thoracic aorta abnormalities (5/53), left ventricular systolic function (22/53), endocarditis (6/53), right heart pathology (2/53), pulmonary embolus (2/53), or a potentially surgical correctable lesion (3/53). Findings were categorized into three groups: confirming suspected pathology (18/53), major incidental findings (6/53), or normal (29/53). Patient management was altered, not only by the finding of positive pathology, but also after identifying normal left ventricular systolic function (14/53). Echocardiography has become an invaluable tool in the ICU setting.
Microbial Contamination of Three-Way Taps on Arterial Lines
Authors: Widdowson W. M. , Walker L. , Havill J. H. , Sleigh J. W.
Published: January 2019

Arterial lines with three-way taps are used to measure blood pressure and aspirate blood, and are a potential source of catheter-related sepsis.

Swabs were taken daily from 118 three-way taps on 98 arterial lines in a general intensive care unit. Infusion lines were changed weekly but arterial cannulae were not changed routinely.

An overall contamination rate of 24.6% was found with the predominant organism being coagulase negative staphylococcus. The three-way taps became increasingly contaminated with time but this was shown to be unrelated to the manipulation rates. Blood culture organisms in those showing contamination of the three-way taps showed no relationship to the bacteria causing the contamination.
Intravenous Tenoxicam for Analgesia following Laparoscopic Cholecystectomy
Authors: Munro F. J. , Young S. J. , Broome I. J. , Robb H. M. , Wardall G. J.
Published: January 2019

In a double-blind, placebo-controlled clinical trial (power of 80% to detect a 30% reduction in morphine consumption, P<0.05) we have determined that intraoperative intravenous administration of tenoxicam 40 mg during laparoscopic cholecystectomy, when compared with placebo, was associated with a significant reduction in consumption of morphine at 6 hours and 12 hours (P<0.05) but not at 24 hours, when assessed by patient-controlled analgesia. Furthermore there was a significantly greater requirement for “rescue” analgesia with intramuscular morphine in the placebo group during the period of the study. There was no difference between the groups in pain scores, either at rest or on movement, nor in the incidence of nausea and vomiting. No patient in either group suffered a respiratory rate less than 8/min or oversedation at any time, and there were no other adverse effects.
Anti-Aspiration Prophylaxis in New Zealand: A National Survey
Authors: Kluger M. T. , Willemsen G.
Published: January 2019

A postal questionnaire was sent on two occasions to specialist anaesthetists within New Zealand. Questions were related to fasting status, anti-aspiration prophylaxis, incidence of aspiration, definition of high risk groups for aspiration pneumonitis, and identification of departmental guidelines. Two-hundred-and-twenty-three replies were received (72% response rate). Most adults, children and infants were fasted for 6 hours for solids, whilst the majority fasted for 2 to 4 hours for liquids. Two-thirds indicated that they would delay emergency surgery (not life/limb threatening) to optimize gastric emptying. Histamine type 2 receptor antagonists, metoclopramide and cricoid pressure were used commonly, more so in the obstetric population compared to non-obstetric surgery. Preinduction nasogastric intubation and suction were used infrequently. Anti-aspiration prophylaxis was deemed important in morbidly obese patients, those in the third trimester of pregnancy and those with a hiatus hernia, whilst diabetes mellitus, sepsis and renal failure were not considered risk factors for aspiration pneumonitis. 71% of respondents had at least one episode of aspiration (range 0–10), with an overall mortality rate of 5%. Half of these cases of aspiration were deemed to be preventable by the respondent.
Unpacking the Burden: Gender Issues in Anaesthesia
Authors: Khursandi D. C. Strange
Published: January 2019

A survey carried out by the Australian Society of Anaesthetists explored gender issues in the personal and professional lives of anaesthetists. Issues highlighted include training and career paths, combining anaesthetic training with domestic responsibilities, personal relationships, pregnancy and childrearing, private practice, part-time work, parental leave, the single anaesthetist, doctor spouses, sexual harassment, and negative attitudes in colleagues. Particular problems were identified in the training years, in part-time work, in private practice, and in combining parental and domestic responsibilities with a career in anaesthesia. Strategies to address relevant issues are discussed, with reference to the increasing proportion of women in medicine and anaesthesia.
Box Hill Hospital Resuscitation Trolley
Authors: Cranswick P. J. , Rodda M.
Published: January 2019

A resuscitation trolley has been designed to meet the following requirements.

Continuous oxygen supply from the trolley for the duration of the emergency; medical suction of similar strength to that of an ICU treatment bay and provision of equipment and drugs in a modular form, which is uniform across the institution, and which allows immediate replacement from stock.

These requirements have been fulfilled whilst maintaining a total trolley weight and manoeuvrability similar to that of commercially manufactured trolleys available in Australia.
The Preoperative Management of Phaeochromocytoma
Authors: Russell W. J. , Metcalfe I. R. , Tonkin A. L. , Frewin D. B.
Published: January 2019

Although the preoperative use of alpha-receptor antagonist drugs is generally accepted for patients with phaeo-chromocytoma, evidence on the most appropriate treatment and its timing is scarce.

In this retrospective study, the effectiveness of the preoperative preparation of fourteen patients who required surgical excision of a phaeochromocytoma was examined in the light of their operative stability. A simple score was developed of blood pressure stability by scoring the need for additional antihypertensive agents intraoperatively before, and blood pressure support after, tumour removal. A higher score indicated greater instability.

Twelve patients received phenoxybenzamine and their stability was superior to the two patients treated with labetalol and with prazosin. There was no correlation between the duration of treatment with phenoxybenzamine and the operative stability (r=0.18 P=0.55 Spearman). The five patients who were treated with phenoxybenzamine for longer than 10 days did not have better perioperative blood pressure stability than the five patients who had treatment for less than a week.

Predictive factors for intra-operative blood pressure stability were also sought. The degree of postural hypotension after treatment with phenoxybenzamine did not predict operative stability (r=-0.31, P=0.33 Spearman). However, the peak total catecholamine level found during surgery correlated quite well with more operative instability (r=0.65, P=0.031, Spearman), suggesting that patients with phaeochromocytomas with high production of catecholamines are more likely to show cardiovascular instability.
Central Nervous System Toxicity Attributable to Epidural Ropivacaine Hydrochloride
Authors: Plowman A. N. , Bolsin S. , Mather L. E.
Published: January 2019

Ropivacaine, a new local anaesthetic agent, has been demonstrated to have less potential than bupivacaine for central nervous system toxicity on the basis of human and animal studies. We report a case of a convulsion secondary to presumed inadvertent intravascular injection of 20 mg of ropivacaine in a 44 kg patient during an epidural for chronic pain. There were minimal signs of cardiovascular toxicity.
Oxygen Contamination of the Nitrous Oxide Pipeline Supply
Authors: Lye A. , Patrick R.
Published: January 2019

Midogas® (CIG Australia) nitrous oxide/oxygen blenders are commonly used in delivery wards in Australia. In this case report we describe an incident where a small hole in the diaphragm of the oxygen failure alarm in a Midogas nitrous oxide/oxygen blender led to retrograde flow of oxygen contaminating the nitrous oxide pipeline supply to the operating theatres and the delivery ward. This caused a reduced level of nitrous oxide to the patient in theatre, but there was no adverse outcome. However, if the oxygen pipeline pressure had been lower than the nitrous oxide pipeline pressure, the contamination would have been reversed, potentially resulting in a hypoxic mixture being delivered to many patients. Suggestions are made as to a method of prevention of this problem.
Potential Intrathecal Leakage of Solutions Injected into the Epidural Space following Combined Spinal Epidural Anaesthesia
Authors: Vartis A. , Collier C. B. , Gatt S. P.
Published: January 2019

A combined spinal epidural anaesthetic (CSE), by design, produces a deliberate multicompartment block across a breached dural membrane. Since the lateral holes of the epidural catheter may lie in close proximity to the dural puncture site, a bolus solution of drug injected via the epidural catheter has the potential to leak through the dural puncture into the subarachnoid space.

The aim of this study was to determine the incidence of intrathecal leak by performing an epidurogram.

Fifteen patients undergoing surgery with a CSE anaesthetic using a 16 gauge Tuohy/26 gauge pencil point needle were studied. Within three hours of catheter insertion, 12 ml of contrast (iohexol 300 mg/ml) was injected via the epidural catheter under fluoroscopic control with screen recording and exposure of lateral and anteroposterior X-ray plates. All films were later reviewed for evidence of intrathecal spread.

We did not observe any evidence of intrathecal spread of contrast. However, caution should be observed during administration of an intraoperative bolus dose of analgesic agent via a catheter inserted as part of a combined spinal epidural anaesthetic technique, particularly with the use of hydrophilic opiods.
Haemolysis Associated with Continuous Venovenous Renal Replacement Circuits
Authors: Bierer P. , Holt A. W. , Bersten A. D. , Plummer J. L. , Chalmers A. H.
Published: January 2019

Extracorporeal circuits can cause haemolysis resulting in an increase in plasma-free haemoglobin (PFHb). High pressures and clots within the circuit have been identified as factors increasing the likelihood of haemolysis. Continuous venovenous haemodiafiltration (CVVHD) is associated with high circuit pressures as the pump-driven circuit clots over a period of time. PFHb was measured during CVVHD to determine if circuit life, maximum circuit pressure or the clotting of the haemofilter was associated with evidence of haemolysis. Circuit life up to 50 hours, circuit pressures or haemofilter clotting had no significant effect on PFHb. There was a small rise in PFHb in the circuits lasting beyond 50 hours. CVVHD circuits can be run up to 50 hours without concern for haemolysis.
Brown Snakes (Pseudonaja Genus): Venom Yields, Prothrombin Activator Neutralization and Implications Affecting Antivenom Usage
Authors: Masci P. P. , Mirtschin P. J. , Nias T. N. , Turnbull R. K. , Kuchel T. R. , Whitaker A. N.
Published: January 2019

The recent high prevalence of fatal bites by Brown snakes (Pseudonaja genus) has led to this study of venom yields from 66 brown snake milkings over 15 months. The amount of venom obtained from all species was higher than reported previously. Electrophoretic and Western blotting analyses of their venoms showed significantly lower avidity of Brown snake antivenom (BS-AV) for the prothrombin activator (PA) component (190 kD) than for other venom components, including the neurotoxins. The LD50 of P. inframacula has been determined for the first time.

SDS-PAGE (sodium dodecyl sulphate-polyacrylamide gel electrophoresis) and Western blotting studies have shown that the Pseudonaja venoms contained proportionately more PA component than venoms of the Taipan (Oxyuranus scutellatus) or the Fierce snake (O. microlepidotus). Neutralization of the prothrombin activator of the Common Brown snake (P. textilis) (Pt-PA) by BS-AV was found to be time dependent and 40% remained unneutralized after 30 minutes incubation.

Adult rats administered quantities of Pt-PA (IV) died with acute disseminated intravascular coagulation. Rats were made resistant to Pt-PA by preheparinization or by induction of tolerance to increasing quantities of Pt-PA. There is no evidence that Pt-PA has intrinsic toxicity apart from being a procoagulant. The improvement of BS-AV by addressing its deficiencies should be canvassed.
Measuring Line-Related Bacteraemia in Intensive Care Patients
Authors: McLaws M.-L , Murphy C. , Taylor P. , Coroneos N.
Published: January 2019

All patients with an intravascular device in the intensive care units at Prince of Wales and Prince Henry Hospitals between July and September 1995 were followed for the development of line-related bacteraemia per 1000 line days. Cases of sepsis related to an intravascular device were identified using a case definition which incorporated clinical and laboratory parameters. Data were collected prospectively for the dates of insertion and removal of devices for 188 lines inserted in 69 patients. The majority (90%) of lines had both date of insertion and removal documented allowing the calculation of the rate of primary bacteraemia over 832 at-risk line days. Multiple concurrent lines were more common (88.4%) than single lines, with one central and one or two peripheral lines being the most common (42.3%) combination. Five cases of bacteraemia were diagnosed clinically and confirmed microbiologically. The incidence density of primary bacteraemia was 6.0 per 1000 line days (CI95% 5.7-6.3).
Cardiac Arrest Associated with Sulprostone Use during Caesarean Section
Authors: Chen F. G. , Koh K. F. , Chong Y. S.
Published: January 2019

Sulprostone, a synthetic prostaglandin with potent uterotonic action, has been shown to have a low complication rate in a large series. We present a case in which a bolus intravenous injection of sulprostone 30 μg was administered to treat postpartum haemorrhage during caesarean section. The 38-year-old patient with no previous cardiac or smoking history developed complete heart block, ventricular fibrillation and subsequent asystole. Cardiopulmonary resuscitation was successful after 45 minutes. Post resuscitation there was no myocardial infarction and she had complete neurological recovery. We postulate that the bolus of sulprostone resulted in possible coronary spasm that resulted in cardiac arrest.
Central Regional Anaesthesia in a Patient with Klippel-Trenaunay Syndrome
Authors: Christie I. W. , Ahkine P. A. , Holland R. L.
Published: January 2019

A 27-year-old female with Klippel-Trenaunay Syndrome presented for reconstructive surgery of the deep venous system of the right leg. Contrast enhanced dynamic computed tomography was performed to exclude the presence of arteriovenous malformation of the lumbosacral spine. A combined spinal-epidural technique supplemented with light general anaesthesia was performed. The patient's condition was stable throughout the three hours of surgery and postoperative analgesia was maintained successfully for three days.
The Effect of Low-Dose Heparin on Hypercoagulability following Abdominal Aortic Surgery
Authors: Gibbs N. M. , Bell R.
Published: January 2019

The effect of low-dose heparin on postoperative hypercoagulability was assessed using thrombelastography (TEG) in eighteen patients undergoing elective abdominal aortic surgery. Patients received unfractionated heparin 50001U bd SC commencing on the first postoperative day. Native whole blood TEG was performed preoperatively and on day two postoperatively. A heparinase-modified TEG was performed at the same time as the native whole blood TEG on day two. There were no significant changes in the postoperative native whole blood TEG variables (r, K, α, MA) relative to preoperative controls. In contrast, there were significant decreases in r and K, and increases in a in the heparinase-modified TEGs postoperatively (P<0.01). There were significant differences between the postoperative native whole blood and heparinase-modified TEGs for all TEG variables (P<0.01). The results indicate that low-dose heparin reduces postoperative hypercoagulability following abdominal aortic surgery as assessed by thrombelastography.