bluuebunny/crossref_metadata_2025 huggingface dataset:
Failure of Tigecycline to Treat Severe Clostridium Difficile Infection
Authors: Kopterides P. , Papageorgiou C. , Antoniadou A. , Papadomichelakis E. , Tsangaris I. , Dimopoulou I. , Armaganidis A.
Published: January 2019

Clostridium difficile infection is an emerging and often difficult-to-treat iatrogenic complication. Recent data suggest that tigecycline, a novel antibiotic with broad-spectrum antibacterial activity, can be used successfully to treat patients with severe Clostridium difficile infection. We report a 70-year-old man who developed severe Clostridium difficile infection, was admitted to the intensive care unit and eventually succumbed to complications of his illness despite receiving tigecycline for approximately three weeks in combination with vancomycin, metronidazole and intravenous immunoglobulin. Additionally, we discuss the unique challenges that emerged during tigecycline treatment, such as the development of Proteus mirabilis bacteraemia and of colonisation with Acinetobacter baumannii resistant to tigecycline. Finally, we review data on other cases reported in the medical literature. Even though tigecycline looks promising for the treatment of Clostridium difficile infection, we urge caution against its indiscriminate use for off label indications.
Extracorporeal Membrane Oxygenation: An Unusual Cause of Acute Limb Compartment Syndrome
Authors: Wall C. J. , Santamaria J.
Published: January 2019

Acute limb compartment syndrome is a surgical emergency associated with significant morbidity if not diagnosed promptly and treated effectively. We describe a case of severe and eventually lethal acute limb compartment syndrome, which complicated veno-arterial extracorporeal membrane oxygenation in a previously well young woman who had suffered an unexplained cardiac arrest. We recommend that intensive care units develop clinical practice guidelines for the use of extracorporeal membrane oxygenation therapy in order to minimise the risk of similar adverse events in the future.
The Self-Inflating Resuscitator – Evolution of an Idea
Authors: Fahey D. G.
Published: January 2019

Based on animal experiments conducted in the sixteenth century by Vesalius, the Royal Humane Society recommended fireside bellows to resuscitate victims of drowning. In the mid-twentieth century, the bellows concept was adapted by Kreiselman and others, though none of these devices gained widespread popularity. However, in 1957 the “Ambu Bag” appeared and was an immediate success. The revolutionary design was the creation of Danish anaesthetist Dr Henning Ruben. A similar product was soon developed by Åsmund Laerdal of Norway, in collaboration with American anaesthesiologists Drs Elam and Safar. The self-inflating bag is such a simple device, yet it is extremely effective – it has enabled rescuers around the world to support life in virtually any environment, simply by squeezing a bag.
Adverse Events Associated with Regional Ophthalmic Anaesthesia in an Australian Teaching Hospital
Authors: Clarke J. P. , Plummer J.
Published: January 2019

This study prospectively audited 3339 peribulbar and 2688 sub-Tenon's eye blocks in an Australian teaching hospital with regard to the occurrence of adverse events. Complications were classified into three groups: ocular complications directly due to the eye block technique, systemic medical complications possibly associated with block technique and adverse events which were unlikely to have been associated with block technique. Five serious ocular complications were associated with peribulbar block compared to none with sub-Tenon's block (P=0.07).
Cardiovascular Collapse following Povidone-Iodine Wash
Authors: Ramaswamykanive H. , Nanavati Z. , Mackie J. , Linderman R. , Lavee O.
Published: January 2019

We present a case study of a severe episode of iodine toxicity following povidone-iodine wash with clinical manifestations of cardiovascular collapse, metabolic acidosis, renal failure and seizures. Povidone-iodine has been used as a medical antiseptic and disinfectant since 1952. Iodine toxicity secondary to povidone-iodine use is rare. Iodine toxicity is difficult to diagnose and the diagnosis is made by a high index of suspicion. Toxicity due to iodine correlates with serum and urine iodine levels. Treatment of iodine toxicity is supportive.

A review of literature relating to the components of povidone-iodine, iodine metabolism, its manifestations and management of iodine toxicity secondary to povidone-iodine is also presented. An Ovid-Medline search from 1950 to 2009 revealed 1236 articles on the clinical manifestations of povidone-iodine usage but no article on iodine toxicity relating to povidone-iodine based on the following search criteria: povidone-iodine and/or iodine toxicity secondary to povidone-iodine (limited to English language, review articles, full text and human patients).
Reflections of Mesmerism in Literature
Authors: Stanbury P.
Published: January 2019

Controversial procedures in medicine are likely to be discussed in the community as everyone is interested in their health. If the practice is subjective, that is, clear proof is not readily forthcoming, there are likely to be both strong supporters and opponents. In the 18th and 19th centuries, when the dissemination of news was slow, such controversies lasted many years and were likely to appear in novels, drama and poetry of the period. This article gives examples of animal magnetism, mesmerism and hypnosis in contemporary literature.
The Phillips Airway
Authors: Haridas R. P. , Wilkinson D. J.
Published: January 2019

The Phillips airway was developed by George Ramsay Phillips. There is no known original description of the airway and the earliest known reference to it is from 1919. The airway and its modifications are described.
A Prospective Randomised Comparison of the LMA ProSeal™ versus Endotracheal tube on the Severity of Postoperative Pain following Gynaecological Laparoscopy
Authors: Griffiths J. D. , Nguyen M. , Lau H. , Grant S. , Williams D. L.
Published: January 2019

Pain and postoperative nausea and vomiting (PONV) are common problems after gynaecologic laparoscopy. Two recent studies have shown that morphine requirements and PONV are lower when a LMA ProSeal™ is used, rather than an endotracheal tube (ETT), for female patients undergoing breast and gynaecological surgery. We conducted a patient and observer-blinded randomised controlled trial, recruiting non-obese women without gastro-oesophageal reflux undergoing laparoscopic gynaecological surgery. Patients received a standardised relaxant general anaesthetic and then were randomised to receive either an LMA ProSeal or an endotracheal tube. Patients were assessed at two and 24 hours post-anaesthesia. The primary outcome was postoperative pain score and secondary endpoints included morphine consumption, postoperative emesis and adverse upper airway symptoms.

We recruited 116 patients to the study, 57 patients in the ETT group and 59 patients in the LMA ProSeal group. The patients were similar in demographic and surgical characteristics. At two hours, the ETT group was similar to the LMA ProSeal group in regards to pain scores (verbal rating scale 3.0 vs 3.5, P=0.86), morphine consumption (7.2 vs 7.4 mg, P=0.56) and PONV (47.4 vs 47.5%, P=0.99). After 24 hours, pain scores and PONV rates were also similar. No significant difference in rates of sore throat or dysphagia was observed between the ETT and LMA ProSeal groups. No significant complications were attributable to either airway device.

The LMA ProSeal did not decrease pain or PONV in patients undergoing gynaecological laparoscopy when compared to endotracheal intubation.
Oseltamivir Pharmacokinetics in Critically Ill Adults Receiving Extracorporeal Membrane Oxygenation Support
Authors: Mulla H. , Peek G. J. , Harvey C. , Westrope C. , Kidy Z. , Ramaiah R.
Published: January 2019

Extracorporeal membrane oxygenation (ECMO) is known to affect pharmacokinetics and hence optimum dosing. The aim of this open label, prospective study was to investigate the pharmacokinetics of oseltamivir (prodrug) and oseltamivir carboxylate (active metabolite) during ECMO. Fourteen adult patients with suspected or confirmed H1N1 influenza were enrolled in the study. Oseltamivir 75 mg was enterally administered twice daily and blood samples for pharmacokinetic assessment were taken on day 1 and 5. A multi-compartmental model to describe the pharmacokinetics of oseltamivir and oseltamivir carboxylate was developed using a nonlinear mixed effects modelling approach.

The median (range) clearance of oseltamivir carboxylate was 15.8 (4.8–36.6) 1/hour, lower than the reported mean value of 21.5 1/hour in healthy adults. The median (range) steady state volume of distribution of oseltamivir carboxylate was 179 (61–436) litres, much greater than healthy adults but similar to previous reports in critically ill patients. Substantial ‘between subject’ variability in systemic exposure to oseltamivir carboxylate was revealed; median (range) area under the curve and Cmax were 4346 (644–13660) ng/hour/ml and 509 (54–1277) ng/ml, respectively. Both area under the curve and Cmax were significantly correlated with serum creatinine (r2=0.37, P=0.02 and r2=0.29, P=0.02, respectively).

Systemic exposure to oseltamivir carboxylate following the administration of enteral oseltamivir 75 mg twice daily in adult ECMO patients is comparable to those in ambulatory patients and far in excess of concentrations required to maximally inhibit neuraminidase activity of the H1N1 virus. Dosage adjustment for ECMO, per se, appears not to be necessary; however, doses should be reduced in patients with renal dysfunction.
Systemic Mastocytosis Presenting as Intraoperative Anaphylaxis with Atypical Features: A Report of two Cases
Authors: Bridgman D. E. , Clarke R. C. , Sadleir P. H. M. , Stedmon J. J. , Platt P. R.
Published: January 2019

Two cases of perioperative cardiovascular collapse are presented that were associated with markedly elevated mast cell tryptase levels shortly after the event, leading to the assumption that an immunoglobin E-mediated, drug-induced anaphylaxis had occurred. However, the clinical picture in both cases was atypical and subsequent skin testing failed to identify a triggering drug. Further blood tests, some weeks later, revealed persistently elevated baseline levels of mast cell tryptase. In both cases bone marrow biopsy and genetic testing confirmed the diagnosis of mastocytosis. We present evidence and speculate that mast cell degranulation was triggered by tourniquet release in the first case and by exposure to peanuts in the second. An atypical presentation of anaphylaxis should alert the anaesthetist to the possibility of previously undiagnosed mastocytosis.
National Anaesthesia Mortality Reporting in Australia from 1985–2008
Authors: Gibbs N. M.
Published: January 2019

This article summarises the Australian national anaesthesia mortality data from 1985–2008, previously published in eight consecutive triennial reports and covering an estimated 50 million anaesthetics. The data were obtained using consistent definitions and methodology over a 24-year period. Anaesthesia-related mortality in Australia fell from about 1:36,000 anaesthetics in the 1985–1987 triennium to about 1:55,000 for the most recently reported 2006–2008 triennium. The percentage of the deaths considered anaesthesia-caused fell from about 50% of all anaesthesia-related deaths in the 1985–1987 triennium to about 15% of all anaesthesia-related deaths in the 2006–2008 triennium. The percentage of anaesthesia-related deaths considered non-preventable (no correctable anaesthetic factor identified) increased from about 4% in the 1991–1993 triennium to about 50% in the 2006–2008 triennium. There was also an increase in the proportion of deaths in which the patient's medical condition was considered a significant factor in the death over this period. While the trends are encouraging, they nevertheless suggest that additional efforts are required to further reduce ‘preventable’ anaesthetic deaths, and that continuing research and development into safer agents, techniques and approaches are required to reduce the incidence of deaths currently considered ‘non-preventable’.
Can the Presence of Significant Coagulopathy be Useful to Exclude Symptomatic Acute Pulmonary Embolism?
Authors: Ho K. M. , Tan J. A.
Published: January 2019

Thrombocytopaenia or an abnormal coagulation profile is not rare in hospitalised patients who have symptoms consistent with acute pulmonary embolism (PE). Theoretically, coagulopathy is more likely to occur in patients with pneumonia than acute PE. This study aimed to assess whether the presence of coagulopathy could be used to exclude acute PE in patients with symptoms and signs consistent with acute PE. In this study, a significant coagulopathy was defined as a platelet count <100 × 109/l, an international normalised ratio >1.5, or activated partial thromboplastin time >50 seconds. Patients treated with systemic anticoagulants prior to computed tomography pulmonary angiography were excluded. Of the 986 consecutive patients who required computed tomography pulmonary angiography to exclude acute PE over a four-month period in five hospitals in Western Australia, acute PE was confirmed in 149 patients (15.1%). The incidence of coagulopathy was not significantly different between those with and without acute PE (4 vs 7%, respectively; P=0.161) and between those with and without pneumonia (8 vs 7%, respectively; P=0.505). Positive and negative likelihood ratios of coagulopathy in differentiating acute PE or pneumonia were both unsatisfactory. As a continuous predictor, platelet counts, international normalised ratio, activated partial thromboplastin time and plasma fibrinogen concentrations were also not useful in differentiating between acute PE and other pulmonary pathologies (areas under the receiver operating characteristic curve were all close to 0.5). In conclusion, the presence of significant acquired coagulopathy cannot be used to suggest pneumonia or exclude symptomatic acute PE when the prevalence or pre-test probability of acute PE is not low.
Effects of Dexmedetomidine Infusion on Laryngeal Mask Airway Removal and Postoperative Recovery in Children Anaesthetised with Sevoflurane
Authors: He L. , Wang X. , Zheng S. , Shi Y.
Published: January 2019

We investigated the effects of dexmedetomidine infusion on the end-tidal concentration of sevoflurane required for smooth removal of the laryngeal mask airway (LMA) and on the incidence of respiratory complications during postoperative recovery in paediatric patients anaesthetised with sevoflurane. Eighty-seven patients (ASA 1 or 2, aged 3–7 years) were randomly allocated to receive saline (Group C), 0.5 μg/kg dexmedetomidine (Group D1), or 1 μg/kg dexmedetomidine (Group D2) after LMA insertion. A predetermined end-tidal sevoflurane concentration for each patient was determined using the Dixon's up-and-down method (starting at 2.2% and step was 0.2%). The LMA was removed after the predetermined concentration had been maintained stable for five minutes. Sevoflurane minimum alveolar concentration for smooth LMA removal and postoperative recovery were assessed. The end-tidal concentration of sevoflurane required for smooth LMA removal in 50% of children (MACLMA-RM) in Group D2 (0.84±0.15%) was significantly lower than in Group D1 (1.39±0.20%; P=0.003), the latter being significantly lower than in Group C (1.73±0.14%; P <0.001). The incidence of breath-holding was significantly lower in Group D2 (3%) than in Group C (27%;P=0.009), but comparable between Groups D1 (17%) and C (P=0.385). The incidence of severe coughing was significantly lower in Groups D1 (14%) and D2 (6%) as compared to Group C (39%; P=0.005), but comparable between Groups D1 and D2 (P=0.323). In conclusion, dexmedetomidine infusion produced a dose-dependent decrease in the end-tidal concentration of sevoflurane required for smooth LMA removal in children and was associated less agitation in the post-anaesthetic care unit.
Bench Performance of Ventilators during Simulated Paediatric Ventilation
Authors: Park M. A. J. , Freebairn R. C. , Gomersall C. D.
Published: January 2019

This study compares the accuracy and capabilities of various ventilators using a paediatric acute respiratory distress syndrome lung model. Various compliance settings and respiratory rate settings were used. The study was done in three parts: tidal volume and FiO2 accuracy; pressure control accuracy and positive end-expiratory pressure (PEEP) accuracy. The parameters set on the ventilator were compared with either or both of the measured parameters by the test lung and the ventilator.

The results revealed that none of the ventilators could consistently deliver tidal volumes within 1 ml/kg of the set tidal volume, and the discrepancy between the delivered volume and the volume measured by the ventilator varied greatly. The target tidal volume was 8 ml/kg, but delivered tidal volumes ranged from 3.6–11.4 ml/kg and the volumes measured by the ventilator ranged from 4.1–20.6 ml/kg. All the ventilators maintained pressure within 20% of the set pressure, except one ventilator which delivered pressures of up to 27% higher than the set pressure. Two ventilators maintained PEEP within 10% of the prescribed PEEP. The majority of the readings were also within 10%. However, three ventilators delivered, at times, PEEPs over 20% higher.

In conclusion, as lung compliance decreases, especially in paediatric patients, some ventilators perform better than others. This study highlights situations where ventilators may not be able to deliver, nor adequately measure, set tidal volumes, pressure, PEEP or FiO2.
A Survey of Patient Understanding and Expectations of Sedation/Anaesthesia for Colonoscopy
Authors: Chatman N. , Sutherland J. R. , Van Der Zwan R. , Abraham N.
Published: January 2019

One hundred and fifty-nine adult patients undergoing elective colonoscopy in a major regional hospital were surveyed regarding their perceptions and expectations of sedation/anaesthesia for this procedure. The survey was undertaken on the day of the procedure, but before their assessment by the anaesthetist. Most of our patients expected to be completely unconscious and few understood that there was any chance of being aware during any part of their colonoscopy procedure. The perception (level of knowledge) of patients about their sedation/anaesthesia was highly variable, and was influenced both by having had a prior colonoscopy and by having had a discussion with an anaesthetist prior to the day of procedure. Of a range of potential adverse outcomes, procedural awareness generated the highest level of concern. However, those patients who recognised the potential for procedural awareness reported significantly less concern about this potential occurrence than patients who were unaware of the possibility. Our findings suggest that explicit discussion of the possibility of procedural awareness during colonoscopy should be considered by clinicians who administer sedation or anaesthesia for colonoscopy. Knowledge of this potential source of patient confusion and anxiety may enable clinicians to better target the pre-procedural discussion, in order to more appropriately inform patient expectations.
Bedside Pleuroscopy in the Management of Undiagnosed Exudative Pleural Effusion with Acute Respiratory Failure
Authors: Hean O. , Shang-Miao C. , Chien-Ming L. , Kuo-Liang C. , Jeng-Yuan W. , Nanyung H. , Bor-Tsung H.
Published: January 2019

Pleuroscopy is indicated in patients with acute respiratory failure due to an unresolved exudative pleural effusion but it may not be possible to move such patients to the operating theatre or endoscopy room for pleuroscopy due to their critical condition. We report our experience of using flexible bronchoscopy for pleuroscopy to diagnose pleural effusion in patients with acute respiratory failure at the bedside in the intensive care unit. Before pleuroscopy patients were placed in the lateral decubitus position. We used bedside chest sonography to guide safe entry of the trocar. The skin was sterilised with povidone-iodine and local analgesia was with 2% lignocaine. Incisions were made using a knife with a width of 5 mm. A trocar 5.5 mm in diameter was then inserted, followed by a bronchoscope. The pleural cavity was inspected and biopsies were performed under direct vision in all suspected areas. A 16 Fr pigtail catheter was inserted for drainage after the pleuroscopy. Chest radiographs were routinely obtained after the procedure. In summary, this modified pleuroscopy technique can be performed at the bedside in an intensive care unit.
Epidural versus Continuous Transversus Abdominis Plane Catheter Technique for Postoperative Analgesia after Abdominal Surgery
Authors: Kadam V. Rao , Van Wijk R. M. , Moran J. L. , Miller D.
Published: January 2019

Transversus abdominis plane block is an effective postoperative analgesic technique after abdominal surgery, but no study has compared continuous transversus abdominis plane block with continuous epidural analgesia.

We designed a randomised controlled trial comparing these techniques for major abdominal surgery. Patients in the epidural group received a bolus of 8 to 15 ml of ropivacaine 0.2% and an infusion of 5 to 15 ml/hour and the transversus abdominis plane block group a bolus dose of 20 ml of ropivacaine 0.375% bilaterally and an infusion of 0.2% ropivacaine 8 ml/hour bilaterally, for three days. Both groups received paracetamol and patient controlled analgesia with fentanyl for three days. Primary outcomes were numerical rating scores for pain (rest and dynamic over 72 hours) and total fentanyl use; complications and satisfaction scores were also noted.

The study was terminated early after 42 patients had been randomised (epidural n=19; transversus abdominis plane block n=22; one excluded). No differences were found in regards to point pain scores or scores over time, either immediately postoperatively or in surgical wards; total fentanyl requirement and Likert satisfaction scores were also similar in both groups. In this underpowered study we found comparable results between continuous transversus abdominis plane technique and epidural analgesia in regard to pain, analgesic use and satisfaction after abdominal surgery. To confirm this finding, randomised trials with larger numbers of participants are needed.
Is Comorbid Status the Best Predictor of One-Year Mortality in Patients with Severe Sepsis and Sepsis with Shock?
Authors: Huddle N. , Arendts G. , Macdonald S. P. J. , Fatovich D. M. , Brown S. G. A.
Published: January 2019

Understanding longer term outcomes in critically ill patients will assist treatment decisions, allocation of scarce resources and clinical research in that population. The aim of this study was to compare a well-validated means of determining comorbidity, the Charlson Comorbidity Score, to other verified risk stratification models in predicting one-year mortality and other outcomes in emergency department patients with severe sepsis and sepsis with shock. We conducted a planned subgroup analysis of a prospective observational study, the Critical Illness and Shock Study, in adult patients with sepsis meeting study criteria for critical illness. From emergency department arrival, patients were prospectively enrolled with data collected for a minimum of one year post-enrolment. Scoring systems were derived from this data and compared using receiver-operating characteristic curves. One hundred and four patients were enrolled. The 28-day mortality was 18% and one-year mortality 40%. For predicting one-year mortality, the area under the receiver-operating characteristic curve for age-weighted Charlson Comorbidity Score (0.71, 95% confidence interval 0.61 to 0.81) was at least as good or superior to other scoring systems analysed. The intensive care unit admission rate was 45% and the median hospital length-of-stay was eight days. We conclude that in patients who present to the emergency department with severe sepsis or sepsis with shock, age-weighted Charlson Comorbidity Score is a predictor of one-year mortality that is simple to calculate and at least as accurate as other validated scoring systems.
Chronic Pain after Caesarean Delivery: An Australian Cohort
Authors: Liu T. T. , Raju A. , Boesel T. , Cyna A. M. , Tan S. G. M.
Published: January 2019

We investigated the incidence of and risk factors for persistent pain after caesarean delivery. Over a 12-month period, women having caesarean delivery were recruited prospectively at an Australian tertiary referral centre. Demographic, anaesthetic and surgical data were collected and at 24 hour follow-up, women were assessed for immediate postoperative pain and preoperative expectations of pain. Long-term telephone follow-up was conducted at two and 12 months postoperatively. Complete data were obtained from 426 of 469 women initially recruited (90.6%). The incidence of persistent pain at the abdominal wound at two months was 14.6% (n=62) but subsequently reduced to 4.2% (n=18) at 12 months. At two months, 33 patients (7.8%) experienced constant or daily pain. At 12 months, five patients (1.1%) continued to have constant or daily pain which was mild. There was no apparent increase in incidence of persistent pain associated with general versus regional anaesthesia (relative risk [RR] 0.89, 95% confidence interval [CI] 0.49 to 1.6); emergency vs elective procedure (RR 0.65, 95% CI 0.39 to 1.07); higher acute pain scores (RR 1.1, 95% CI 0.69 to 1.75); or history of previous caesarean delivery (RR 0.81, 95% CI 0.50 to 1.33). Persistent pain, usually of a mild nature, is reported by some women two months after their caesarean delivery, but by 12 months less than 1% of women had pain requiring analgesia or affecting mood or sleep. All declined a pain clinic review. Clinicians and patients can be reassured that caesarean delivery is unlikely to lead to severe persistent pain in the long-term.
Prediction of Fluid Responsiveness Using Dynamic Preload Indices in Patients Undergoing Robot-Assisted Surgery with Pneumoperitoneum in the Trendelenburg Position
Authors: Chin J. H. , Lee E. H. , Hwang G. S. , Hwang J. H. , Choi W. J.
Published: January 2019

We investigated the abilities of pulse pressure variation (PPV) and stroke volume variation (SVV) to predict fluid responsiveness during robot-assisted laparoscopic prostatectomy, requiring pneumoperitoneum and the Trendelenburg position. In 42 patients without cardiopulmonary disease, PPV and SVV were measured before and after administration of 500 ml colloid under pneumoperitoneum combined with the steep Trendelenburg position (35°). Fluid responsiveness was defined as a >15% increase in stroke volume after the fluid loading measured using transoesophageal echocardiography. Of the 42 included patients, 22 were responders and 20 were non-responders. A PPV of >9.5% identified responders with a sensitivity of 77.3% and a specificity of 90.0%, and a SVV of >9.5% also identified responders with a sensitivity of 77.3% and a specificity of 75.0%. The area under receiver operating characteristic curves for PPV and SVV were 0.87 (P <0.001) and 0.81 ( P=0.001), respectively. The findings suggest that both PPV and SVV could be useful predictors of fluid responsiveness in patients without cardiopulmonary disease undergoing robotic laparoscopic surgery with pneumoperitoneum in the Trendelenberg position.
Asialoglycoprotein Receptor Scintigraphy with 99mTc-Galactosyl Human Serum Albumin (99mTc-GSA) as an Early Predictor of Survival in Acute Liver Failure
Authors: Tatsumi H. , Masuda Y. , Imaizumi H. , Yoshida S. , Goto K. , Yama N. , Mizuguchi T. , Hirata K.
Published: January 2019

This study evaluated the usefulness of asialoglycoprotein receptor scintigraphy with 99mTc-galactosyl human serum albumin (99mTc-GSA scintigraphy) as an early predictor for prognosis of acute liver failure. Forty-eight patients with acute liver failure and without a past history of chronic liver disease were enrolled. Patients were divided into survival and non-survival groups by 28-day mortality. 99mTc-GSA scintigraphy to detect uptake ratio of the heart at 15 minutes to that at three minutes (HH15) and uptake ratio of the liver at 15 minutes to the liver plus the heart at 15 minutes (LHL15), and measurements of serum total bilirubin, hepatocyte growth factor and prothrombin time were performed immediately after the diagnosis of acute liver failure. Areas under the receiver operating characteristic curves were used to compare the prognostic ability of total bilirubin, hepatocyte growth factor, prothrombin time, HH15 ratio, LHL15 ratio and the model for end-stage liver disease score. Clinical characteristics of patients in the survival group (n=20) and in the non-survival group (n=28) were not significantly different. HH15 and LHL15 uptake ratios in the survival group were 0.670 and 0.875, and they were significantly lower and higher than those in the non-survival group, respectively. All patients with LHL15 <0.760 died, and the area under the receiver operating characteristic curve for LHL15 were significantly larger than the areas under the receiver operating characteristic curves of serum variables and model for end-stage liver disease score. In summary, in patients with acute liver failure without chronic liver disease, HH15 and LHL15 of 99mTc-GSA scintigraphy are more useful variables in predicting prognosis than serum variables and model for end-stage liver disease score.
Differential Associations between Body Mass Index and Outcomes after Elective Adult Cardiac Surgery: A Linked Data Cohort Study
Authors: Ho K. M. , Bertenshaw C. , Same S. , Schneider M. , Williams K. A. , Godsell L. , Hird K.
Published: January 2019

This study assessed the relationships between body mass index (BMI) and different outcomes after adult cardiac surgery by linking detailed preoperative comorbidity data with the long-term mortality and morbidity outcomes of 2131 consecutive patients who had elective cardiac surgery at a major cardiac surgical hospital in Western Australia. Patients with a high BMI had more comorbidities and were more likely to have had coronary artery bypass grafting than valve surgery. A total of 143 patients (6.7%) died during a median follow-up period of 30 months. The major causes of death were congestive heart failure (25.9%), myocardial infarction (14.7%), infection (23.8%) and cancer (13.9%). BMI had no association with long-term mortality, after adjusting for important confounders including the Charlson Comorbidity Index. BMI had a relatively linear relationship with the risk of new-onset atrial fibrillation (odds ratio 1.05 per point increment, 95% confidence interval 1.03 to 1.05) and venous thromboembolism (odds ratio 1.20, 95% confidence interval 1.14 to 1.26). BMI was the second most important predictor after age and accounted for 22% of the variability in the risk of atrial fibrillation. BMI had an inverse relationship with the risk of requiring allogeneic blood transfusion, postoperative intra-aortic balloon pump, or surgical re-exploration. In summary, BMI had differential associations with different short- and long-term outcomes after elective adult cardiac surgery. After adjusting for important confounders including the presence of cancers, we did not observe any ‘obesity paradox’ and patients with a high BMI were not associated with an increased probability of long-term survival.
A Preliminary Evaluation of Plasma B-Type Natriuretic Peptide as a Screening Test for Left Ventricular Diastolic Dysfunction in Non-Cardiac Intensive Care
Authors: Sturgess D. J. , Parmar D. , Dulhunty J. M. , Hegde R. , Jarrett P. , Udy A.
Published: January 2019

Left ventricular filling and thus diastolic function are frequently monitored and managed in critical care. However, scant data exist regarding possible screening tests for diastolic dysfunction in the intensive care unit (ICU). The present study aimed to evaluate plasma b-type natriuretic peptide (BNP) as a marker of diastolic dysfunction in a single-centre cohort of ‘non-cardiac’ ICU patients. The ICU is non-cardiac in that it provides mixed medical/surgical services with the exception of cardiology, cardiac surgery and solid organ transplantation.

Clinical data were recorded over the first 24 hours of ICU stay for 32 consecutive patients. Transthoracic echocardiogram and blood collection for BNP assay were then performed. Diastolic dysfunction was demonstrated in 34% (n=11). Mean ± standard deviation BNP values were higher with diastolic dysfunction (238±195 vs 72±78 pg/ml; P=0.003). A BNP threshold of >43 pg/ml yielded a sensitivity of 80% and a specificity of 59%; area under the receiver operating characteristic curve was 0.82. BNP correlated independently with E/e’ (R = 0.425; P=0.015) (E/e’: peak early transmitral velocity [E]/early diastolic mitral annular velocity [e']) but not left ventricular ejection fraction ( P=0.8), illness severity (Acute Physiological and Chronic Health Evaluation II; P=0.3) or fluid balance ( P=0.4).

Diastolic dysfunction was common in this cohort of non-cardiac ICU patients and was independently associated with a significantly higher BNP. The potential application as a screening test for diastolic dysfunction is likely to require a threshold lower than previously proposed for heart failure.
Training for Cricothyroidotomy
Authors: Shetty K. , Nayyar V. , Stachowski E. , Byth K.
Published: January 2019

Cricothyroidotomy is infrequently performed in the intensive care unit but may be a lifesaving procedure. The aim of this study was to determine the number of attempts required by trainees to gain adequate skills for a successful cricothyroidotomy (defined as lung inflation <60 seconds). The effect of training on time to completion of cricothyroidotomy was also studied. After viewing a demonstration video on the procedure, each participant attempted cricothyroidotomy five times consecutively on a manikin with a pre-assembled Melker cricothyroidotomy kit. Time from ‘skin’ palpation to ‘lung’ inflation was recorded for 30 participants. Time to completion of cricothyroidotomy decreased over consecutive attempts within each participant (F4df=39.6; P <0.001) and between participant variability in times recorded at each attempt also decreased ( P=0.04). Overall improvement in time to completion was seen even between the fourth and fifth attempts (mean difference −6.3 seconds; P <0.001). All participants were successful by the fifth attempt, by which stage all but two had been successful on two consecutive attempts. Age, years of postgraduate practice and level of seniority appeared to be associated with earlier success. Consecutive attempts on a manikin led to an improvement in the time to completion of cricothyroidotomy and rate of a successful outcome (<60 seconds). We recommend that clinicians undergo at least five training attempts on a manikin to gain proficiency in cricothyroidotomy.
Approaches to Learning for the ANZCA Final Examination and Validation of the Revised Study Process Questionnaire in Specialist Medical Training
Authors: Weller J. M. , Henning M. , Civil N. , Lavery L. , Boyd M. J. , Jolly B.
Published: January 2019

When evaluating assessments, the impact on learning is often overlooked. Approaches to learning can be deep, surface and strategic. To provide insights into exam quality, we investigated the learning approaches taken by trainees preparing for the Australian and New Zealand College of Anaesthetists (ANZCA) Final Exam. The revised two-factor Study Process Questionnaire (R-SPQ-2F) was modified and validated for this context and was administered to ANZCA advanced trainees. Additional questions were asked about perceived value for anaesthetic practice, study time and approaches to learning for each exam component. Overall, 236 of 690 trainees responded (34%). Responses indicated both deep and surface approaches to learning with a clear preponderance of deep approaches. The anaesthetic viva was valued most highly and the multiple choice question component the least. Despite this, respondents spent the most time studying for the multiple choice questions. The traditionally low short answer questions pass rate could not be explained by limited study time, perceived lack of value or study approaches. Written responses suggested that preparation for multiple choice questions was characterised by a surface approach, with rote memorisation of past questions. Minimal reference was made to the ANZCA syllabus as a guide for learning. These findings indicate that, although trainees found the exam generally relevant to practice and adopted predominantly deep learning approaches, there was considerable variation between the four components. These results provide data with which to review the existing ANZCA Final Exam and comparative data for future studies of the revisions to the ANZCA curriculum and exam process.
Home blood pressure monitoring in an anaesthetic pre-admission clinic
Authors: Franks R. M. , Macintyre P. A.
Published: January 2019

We suspected that many high blood pressure measurements taken in our anaesthetic pre-assessment clinic and immediately prior to induction of anaesthesia were unusually elevated due to a ‘white coat’ effect. These high blood pressure measurements were causing late cancellations of surgery, even though white coat measurements may not be representative of the patient's usual blood pressure or of their risk of end-organ damage due to hypertension. In this audit, patients with high blood pressure in our pre-admission clinic were provided with training and a home blood pressure monitor to use prior to surgery. These were compared to the pre-admission clinic measurements to determine the incidence of white coat hypertension. We also compared home to general practice blood pressure monitoring where possible. Fifty-two patients were provided with monitors. Fifty-one of these took at least five measurements at home. Thirty-four (66%) patients had average measurements at home at least 20 mmHg lower than pre-admission clinic measurements. A total of 33% of general practice clinic measurements were also ≥20 mmHg higher than average home measurements. White coat hypertension was common in our audit population. Relying on average home blood pressure measurements rather than ‘one off in-hospital measurements may have helped to prevent the postponement or cancellation of surgery for 13 patients who had recorded blood pressure ≥ 180/110 mmHg in our pre-admission clinic.
Implications for Australian Anaesthetists and Proceduralists of a Recent Court Decision regarding Informed Consent and Patient Positioning
Authors: Breen D. T. , Mahar P. D. , Batty L. M. , Rosenfeld J. V.
Published: January 2019

This article discusses the medicolegal implications of a recent judgment in relation to a patient who suffered significant morbidity as a result of patient positioning during an operative procedure. The patient developed an unexpected serious complication following surgery, in the context of a preoperative consent that did not cover every potential complication or contingency. The court held that the failure to warn of a particular risk that would have prevented the patient from undergoing a procedure but did not occur will not necessarily result in a finding of negligence in relation to another risk where the harm did occur. This finding is well aligned to current clinical practice and at the same time does not abrogate the practitioner's duty to provide a comprehensive list of possible complications during the consent process for any proceduralist. In the context of a procedure requiring anaesthesia, the importance of communication and understanding between the anaesthetist and proceduralist as to which aspects of the consent process are undertaken by whom, and to ensure the process is done comprehensively, is of great importance and is indirectly highlighted by this recent judgment.
Parecoxib and Paracetamol for Pain Relief following Minor Day-Stay Gynaecological Surgery
Authors: Mohamad A. H. , Mcdonnell N. J. , Bloor M. , Nathan E. A. , Paech M. J.
Published: January 2019

Paracetamol and non-steroidal anti-inflammatory drugs are often administered for postoperative analgesia. Dilatation and curettage, with or without hysteroscopy, is a common day-stay procedure that is associated with pain that is partly mediated by prostaglandins. This study aimed to investigate the analgesic efficacy of adjunctive paracetamol and parecoxib in this setting. A randomised, blinded, placebo-controlled, single-centre trial was conducted among 240 women undergoing dilatation and curettage. Patients were randomised intraoperatively into one of four groups, to receive either intravenous paracetamol 2 g, intravenous parecoxib 40 mg, both in combination, or placebos, post-induction and with intravenous fentanyl. The primary endpoints were pain score one hour postoperatively and the Overall Benefit of Analgesia Score. There were no statistically significant differences in primary outcomes across groups. The area under the curve for pain scores to two hours postoperatively was significantly lower in the group receiving paracetamol ( P=0.018) and the need for rescue analgesia with tramadol was less in the combination group ( P=0.02). There were no significant differences in patient satisfaction or recovery. We conclude that paracetamol or parecoxib does not produce a clinically important reduction in pain in this setting. Women having uterine curettage and receiving intravenous fentanyl do not appear to benefit from administration of these non-opioid analgesics.
Clarifying the Role of Activated Charcoal Filters in Preparing an Anaesthetic Workstation for Malignant Hyperthermia—Susceptible Patients
Authors: Bilmen J. G. , Gillies R. L.
Published: January 2019

Malignant hyperthermia (MH) is a life-threatening condition caused by exposure of susceptible individuals to volatile anaesthetics or suxamethonium. MH-susceptible individuals must avoid exposure to these drugs, so accurate and reproducible processes to remove residual anaesthetic agents from anaesthetic workstations are required. Activated charcoal filters (ACFs) have been used for this purpose. ACFs can reduce the time for preparing an anaesthetic workstation for MH patients. Currently, the only commercially available ACFs are the Vapor-Clean™ (Dynasthetics, Salt Lake City, UT, USA) filters which retail at approximately AUD$130 per set of two, both of which are to be used in a single anaesthetic. Anaesthetic workstations were saturated with anaesthetic vapours and connected to a Miran ambient air analyser (SapphIRe XL, LhermoScientific, Waltham, MA, USA) to measure vapour concentration. Various scenarios were tested in order to determine the most economical configurations of machine flushing, component change and activated charcoal filter use. We found that placement of filters in an unprepared, saturated circuit was insufficient to safely prepare an anaesthetic workstation. Following flushing of the anaesthetic workstation with high-flow oxygen for 90 seconds, a circuit and soda lime canister change and the placement of an ACF on the inspiratory limb, we were able to safely prepare a workstation in less than three minutes. A single filter on the inspiratory limb was able to maintain a clean circuit for 12 hours, with gas flows dropped from 10 1pm to 3 1pm after 90 minutes or removal of the filter after 90 minutes if high gas flows were maintained.
Intraoperative Anaphylaxis to Sugammadex and a Protocol for Intradermal Skin Testing
Authors: Sadleir P. H. M. , Russell T. , Clarke R. C. , Maycock E. , Platt P. R.
Published: January 2019

Sugammadex is a selective binding agent for aminosteroid neuromuscular blockers whose use is increasing in anaesthetic practice. We present three cases of severe anaphylaxis coincident with sugammadex administration. Subsequent intradermal testing confirmed sugammadex as the triggering agent, with all patients having positive skin responses to a 1:100 dilution of the standard 100 mg/ml solution and two out of three having a positive response to a 1:1000 dilution. As all patients were administered sugammadex to reverse neuromuscular blockade with rocuronium, we considered that sugammadex–rocuronium complexes were a potential unique allergen. In the two patients who were additionally tested with a rocuronium–sugammadex (3.6:1 molecular ratio) mixture, the wheal-and-flare response was significantly attenuated.
The Dosing and Monitoring of Argatroban for Heparin-Induced Thrombocytopenia during Extracorporeal Membrane Oxygenation: A Word of Caution
Authors: Phillips M. R. , Khoury A. L. , Ashlon R. F. , Cairns B. A. , Charles A. G.
Published: January 2019

Heparin-induced thrombocytopenia is a serious complication of heparin use. Treatment includes discontinuation of heparin and initiation of alternative anticoagulation therapy. In extracorporeal membrane oxygenation anticoagulation is mandatory, and direct thrombin inhibitors (DTIs) have been approved in these cases. However, the use and monitoring of DTIs in extracorporeal membrane oxygenation patients is not well described. DTI use is also complicated by the imprecision of available monitoring tests and currently recommended dosing has been shown to result in a supratherapeutic anticoagulative state. This case report describes the successful use of the DTI argatroban as an alternative anticoagulant in a patient with heparin-induced thrombocytopenia requiring extracorporeal membrane oxygenation support.
Determinants of the Relationship between Cost and Survival Time after Elective Adult Cardiac Surgery
Authors: Ho K. M.
Published: January 2019

Cardiac surgery is increasingly performed on elderly patients with multiple comorbid conditions, but the determinants of the relationship between cost and survival time after cardiac surgery for patients with a serious cardiac condition remain uncertain. Using the long-term outcome data of a cohort study on adult cardiac surgical patients, the relationship between cost and survival time after cardiac surgery from a hospital service perspective was determined. The total cost for each patient was estimated by the costs of the surgical procedures, intra-aortic balloon pump utilisation, operating theatre utilisation, blood products, intensive care unit stay and cumulative hospital stay up to a median follow-up time of 30 months. Of the 2131 patients considered in this study, a total cost >A$100,000 per life-year after cardiac surgery was observed only in 171 patients (8.0%, 95% confidence interval 6.9 to 9.3%). Age, Charlson Comorbidity Index and EuroSCORE were all related to the cost per life-year after cardiac surgery, but EuroSCORE (odds ratio 1.26 per score increment, 95% confidence interval 1.18 to 1.35, P=0.001) was, by far, the most important determinant and explained 32% of the variability in cost per life-year after cardiac surgery. Patients with a high EuroSCORE were associated with a substantially longer length of intensive care unit stay and cumulative hospital stay, as well as a shorter survival time after cardiac surgery compared to patients with a lower EuroSCORE. Of all the subgroups of patients examined, only patients with a EuroSCORE >5 were consistently associated with a cost >A$100,000 per life-year (cost per life-year $183,148, 95% confidence interval 125, 394 to 240, 902).