bluuebunny/crossref_metadata_2025 huggingface dataset:
Increasing the Use of an Existing Medical Emergency Team in a Teaching Hospital
Authors: Jones D. A. , Mitra B. , Barbetti J. , Choate K. , Leong T. , Bellomo R.
Published: January 2019

Cultural barriers in hospital ward staff may limit the use of a Medical Emergency Team (MET) service. In December 2000 the role of the existing Code Blue team in our hospital was expanded to incorporate review of patients fulfilling commonly employed MET criteria. Between January 2001 and June 2003, the average call rate was only 9.8 calls/1000 admissions. Anecdotal feedback and a group-administered questionnaire conducted in July 2003 demonstrated a number of obstacles to initiating calls and the system was modified in October 2004. Specifically, emergency response calls were separated into Code Blue calls (for cardiorespiratory arrests) and MET calls (with physiological and worried criteria). Further, loud overhead chimes as well as anaesthetist and cardiologist attendance were used only in the case of Code Blue calls (suspected arrests). Finally, the heart rate and respiratory rate criteria for MET service activation were modified.

In the 12 months before the intervention (October 2003 to September 2004) there were 817 emergency response calls and 51,963 admissions (15.7 calls/1000 admissions). In the 12 months after the intervention there were 1349 emergency response calk (Code Blue plus MET calk) and 54,593 admissions (24.7 calls/1000 admissions [OR 1.59; 95% CI=1.45–1.73; P<0.0001]).

Our findings suggest that increasing the use of an existing service to review patients fulfilling MET criteria requires repeated education and a periodic assessment of site-specific obstacles to utilization.
Epidural Analgesia for Labour in a Patient with a Neural Tube Defect
Authors: Altamimi Y. , Pavy T. J. G.
Published: January 2019

This report describes the use of epidural analgesia in a patient with a known neural tube defect. The patient had a severe form of spina bifida cystica which had been operated on in childhood. She had a neurogenic bladder but otherwise had preserved neurological function. She had an epidural catheter inserted in early labour, providing effective analgesia for an uneventful birth. This case outlines the severity of the cystica category of neural tube defects, the added anatomical challenges of previous surgery and the difficulties that may arise from the utilization of epidural analgesia. The case demonstrates that epidural analgesia can be utilized despite such a disorder. A thorough history and examination are essential, as are the patient's informed consent and knowledge of possible complications.
Locally Developed Guidelines Reduce Immediate Complications from Percutaneous Dilatational Tracheostomy Using the Ciaglia Blue Rhino Technique: A Report on 200 Procedures
Authors: Cosgrove J. F. , Sweenie A. , Raftery G. , Carey S. M. , Kilner A. J. , Nesbitt I. D. , Cressey D. M. , Hirschauer N. , Laws P. G. , Ryan D. W.
Published: January 2019

Ciaglia Blue Rhino percutaneous dilatational tracheostomy is used as an aid to ventilatory weaning. It carries an immediate complication rate previously reported in 100 consecutive patients by Fikkers et al at 6% for “major” complications and 30% for “minor” complications. Mortality has been associated with the procedure. Our institution has performed dilatational percutaneous tracheostomy since 1998 and used the Blue Rhino technique since 2002. Consensus guidelines were developed following initial experiences. They focus on preoperative risk assessment including levels of ventilatory support and anatomical considerations, seniority of staff, use of bronchoscopy and capnography and correction of coagulopathies. Following introduction of the guidelines we conducted an audit of the first 200 Ciaglia Blue Rhino tracheostomies performed. There was an immediate major complication rate of 3% and minor complication rate of 18%. No deaths occurred within 24 hours of the procedure. We conclude that applying our consensus guidelines produced an immediate complication rate for Ciaglia Blue Rhino percutaneous dilatational tracheostomy below published audits.
Changes in Clinical Research in Anaesthesia and Intensive Care from 1974–2004
Authors: Teoh D. C. A. , Schramm B.
Published: January 2019

The purpose was to identify how the quality of anaesthesia research has improved from articles published in Anaesthesia and Intensive Care over 25 years. Original papers were included during the periods 1974–1978 and 2000–2004. Each article was classified according to principal research designs and the two five-year periods were compared. All interventional trials were evaluated according to the following a priori criteria: author number; ethics approval; informed consent; competing financial interest; eligibility criteria; sample size calculation; method of randomization; patients accounted for, blind assessment of outcome; adverse outcomes; statistical method stated; type I error; type II error; and anaesthetic department of origin. Comparisons of above criteria were made between the two groups using chi-square test or Fischer's exact test. Two-hundred-and-ninety-two articles were reviewed in 1974–1978 and 529 articles were reviewed in 2000–2004. Animal/laboratory articles decreased from 17.47% to 12.28% (P=0.05). Review articles decreased from 34.35% to 10.4% (P<0.0001). Descriptive trials increased from 28.4% to 52.72% (P<0.0001). Interventional trials increased from 18.84% to 22.31% (P=0.269). Uncontrolled clinical trials decreased from 27.27% to 12.71%, non-randomized controlled trials decreased from 50.91 % to 7.63%, and randomized controlled trials increased from 21.82% to 79.66% (P<0.0001). All interventional trials criteria improved and were statistically significant except competing financial interest, method of randomization, patients accounted for, and type II error. The quality of anaesthetic research has improved in Anaesthesia and Intensive Care over the past 30 years. However, there is still room for improvement.
Facilitating Learning in the Operating Theatre and Intensive Care Unit
Authors: Jones R. W. , Morris R. W.
Published: January 2019

Almost every aspect of anaesthetic and intensive care practice can be taught within the operating theatre and intensive care unit. This includes knowledge in the areas of medicine, anatomy, pharmacology, physiology, measurement and statistics, invaluable psychomotor and global skills and abilities, as well as the many important non-clinical aspects of anaesthesia and intensive care including effective communication, leadership, management, ethics and teaching. The operating theatre and intensive care unit offer many advantages and pose numerous challenges to education. This paper briefly discusses what can be taught in the operating theatre and intensive care unit, the educational challenges and benefits of teaching in these unique environments, implications for teaching and what consultants and trainees can do to positively influence the educational activity. The paper concludes with suggestions for facilitating learning in the operating theatre and intensive care unit including the Soldier's Five, practice vivas, skills training, endoscopic dexterity, interesting article exchange, in-service sessions, electronic resources and use out of hours.
Pseudoanaphylaxis
Authors: Russell W. J. , Smith W. B.
Published: January 2019

Profound hypotension and cardiac arrest after commencement of combined spinal and general anaesthesia in a patient for knee replacement surgery raised the suspicion of anaphylaxis. This seemed to be confirmed when a mast cell tryptase test taken about 90 minutes after the onset of the hypotension was elevated. However, subsequent intradermal skin testing twelve weeks later did not identify a causal drug. Repeat mast cell tryptase at the time showed the same elevation, which led to the correct diagnosis of mastocytosis and a secondary diagnosis that the patient's hypotension and cardiac arrest were the result of her spinal anaesthesia.

If the serum tryptase is elevated during the event but no allergic agent can be identified, a further serum tryptase should be taken several weeks later to exclude a persistent elevation due to mastocytosis.
The Early Development of Intravenous Apparatus
Authors: Ball C.
Published: January 2019

Modern anaesthetists rely on the intravenous route for administration of drugs and fluids. This paper traces the development of intravenous equipment from the first, tentative experiments with the intravenous route through to the first intravenous cannulas.
The Contribution of Newspapers and Their Advertisements to the History of Colonial Anaesthesia
Authors: Newson A. J.
Published: January 2019

The first news to reach New Zealand about the beneficial effects of inhalation of ether during surgical operations arrived in Wellington on Sunday July 4 1847. This was 283 days after the first successful demonstration in Boston. The mail services that brought this news and the original source of this news are described.

After this news had reached Wellington, it then took another 84 days before the first successful trial of the agent took place in the recently opened Wellington Colonial Hospital. This period of eighty-four days com-pares unfavourably with those for Sydney and Cape Town. The reasons for this delay are discussed and using information available in the local Sydney and Wellington newspapers, the delay is shown to have been due to the unavailability of supplies of the necessary chemical reagents.
The Inventors
Authors: Holland R.
Published: January 2019

Amongst Australian anaesthetists there have been many whose ingenuity and mechanical knowledge produced ingenious devices. Lidwill and Geoffrey Kaye come immediately to mind, and their contributions are well-described elsewhere. In this paper, two inventions with contrasting fates are described: the Grant Humidifier and the Komesaroff single-use analgesia device.

Graham Grant's invention addressed the problem of rain-out in a most ingenious manner. The device was compact, efficient and deserved greater commercial success, but a similar apparatus developed in New Zealand was better supported and captured most of the market. Grant has a degree in engineering, acquired before his medical degree, but David Komesaroff spent only a year in the Engineering Faculty before transferring to Medicine. Nevertheless, he has remained interested and in touch with technical matters, and has a number of other devices to his credit. Mention is briefly made of others: Stokes (of the suction bullet), Bill Cole (an early volatile specific vaporiser), Fisk (the paediatric ventilator) and Noel Cass (the Cass needle)

These achievements are by no means the end of the road. Already an Australian-designed single-use laryngoscope is being manufactured and launched on both the national and international markets.
Pulsed Radiofrequency: A Critical Review of Its Efficacy
Authors: Malik K. , Benzon H. T.
Published: January 2019

Pulsed radiofrequency is a growingly popular pain treatment modality. However, its clinical efficacy remains controversial. In this review, the available literature on pulsed radiofrequency is critically analysed to determine its clinical efficacy. Our search of the literature for pulsed radiofrequency yielded 341 citations; after reviewing the abstracts we found 51 relevant articles. There were 4 review articles: 44 articles pertained to the application of pulsed radiofrequency by an electrode placed in the vicinity of a neural structure. Of these only two were randomised controlled trials. Of the remaining 42 articles, one was a non-randomised controlled trial, three were prospective uncontrolled trials: there were six retrospective studies, 11 case reports, eight laboratory studies, two position papers, five editorials and seven items of correspondence, while one publication reported two studies. Three articles pertained to transcutaneous application of pulsed radiofrequency. Of the two randomised controlled trials, one reported efficacy of the pulsed radiofrequency while the other reported it to be ineffective. The majority of the uncontrolled and observational studies reported clinical efficacy of pulsed radiofrequency, however many of these studies had limitations. Further randomised controlled clinical trials are recommended in order for the practising pain physician to clearly understand the role of pulsed radiofrequency in the treatment of various chronic pain syndromes.
Perioperative Complications in Patients with Drug-Eluting Stents: A Three-Year Audit at Geelong Hospital
Authors: Conroy M. , Bolsin S. N. C. , Black S. A. , Orford N.
Published: January 2019

Drug-eluting stents are a recommended treatment for lesions in the coronary arteries. Stent insertion requires the patient remain on antiplatelet medication for a minimum of six months after insertion. A serious consequence of ceasing antiplatelet medication is late stent thrombosis leading to myocardial infarction in the territory of the drug-eluting stent. Continuing antiplatelet medication can lead to excessive bleeding at the time of surgery. Understanding the risk of complications attributable to bleeding or myocardial ischaemia will help in defining the optimal management of these patients at the time of noncardiac surgery.

This study is a retrospective database analysis and case note review of all patients with drug-eluting stents presenting for noncardiac surgical procedures over a three-year period in one centre.

Twenty-four patients with drug-eluting stents inserted presented for 43 noncardiac surgical procedures. Severe bleeding problems were encountered in one case. Three of 15 patients (20%) who ceased clopidogrel prior to surgery without alternative anti-thrombotic prophylaxis suffered myocardial infarction due to stent thrombosis. Four patients who received alternative anti-thrombotic prophylaxis did not suffer complications. All 19 patients who ceased clopidogrel remained on aspirin prior to surgery.

Patients treated with drug-eluting stents for coronary artery stenosis represent a challenging group of patients for subsequent perioperative management. The risk of myocardial infarction when clopidogrel is stopped prior to surgery is 20%, if alternative anti-thrombotic prophylaxis is not used. This risk persists beyond one year after insertion of drug-eluting stents. Some treatments appear to be effective in reducing the risk of myocardial infarction.
Methods of endotracheal tube placement in patients undergoing pelviscopic surgery
Authors: Hwang J.-Y. , Rhee K.-Y. , Kim J.-H. , Park Y.-S. , Han S.-H.
Published: January 2019

Accidental endobronchial intubation is reported frequently during laparoscopic gynaecological surgery. We performed a prospective randomised study to compare three different methods of endotracheal tube placement in terms of susceptibility of accidental endobronchial intubation in patients undergoing laparoscopic gynaecologic surgery.

The endotracheal tube was positioned by one of three methods: it was secured by palpating at the suprasternal notch while holding the pilot balloon (Group); by placing the 21 cm mark at the upper incisors (Group21cm); or by placing a guide mark, which was made on the surface of the tube 2 cm above the proximal end of the cuff, at the level of the vocal cords (GroupVC). The distance from the tip of endotracheal tube to the carina was measured with the patient in a neutral position (DTC0) and after the formation of pneumoperitoneum in the Trendelenburg position (DTC1).

Eighty-eight patients were enrolled. Pneumoperitoneum and Trendelenburg position caused inward movement of the endotracheal tube toward the carina in 99%. In each group, the mean value of DTC1 was significantly shorter than DTC0 (Group Cuff 3.0 ± 1.1 vs. 1.7 ± 1.0, Group21cm2.5 ± 0.8 vs. 1.1 ± 0.9, Groupvc 3.5 ± 0.7 vs. 2.3 ± 0.8, DTc0 vs. DTC1 respectively)(all P <0.01). Accidental endobronchial intubation occurred in 14%, with the lowest frequency in Groupvc (2.6 %, P <0.01) and the highest in Group21cm, although this was not significantly (P=0.09) different from GroupCuff (26.7% vs. 10.0%).

The incidence of endobronchial intubation was lowest in Groupvc but endobrochial intubation could not be avoided using any of these methods.
The History of Anaesthetic Mortality Reporting
Authors: Fenwick D.
Published: January 2019

Anaesthetists are acutely aware of the legal constraint of reporting to the coroner deaths in association with anaesthesia. The evolution of the office of the coroner in England is presented and the relationship with the discovery and evolution of anaesthesia is examined. The legal and medical climate in the 19th century is described, with some of the key participants named and their roles explained. The 19th century was an age of questioning and exploration, which led to the elucidation of the problems with chloroform and set the path for progress in monitoring in anaesthesia. Comments are made on the development of anaesthetic mortality reporting into its current system and some of the benefits flowing from it. The collaboration of the various state mortality committees in producing a triennial national report is an important way to ensure that the lessons of the past are kept in mind in the present. The author believes that mortality reporting, the analysis of data and the dissemination of information is a valuable field of research, monitoring and educational tool. Primum non nocere is particularly pertinent in anaesthesia.
Airway Experience of Anaesthetic Registrars
Authors: Smith N. , Koutantos A.
Published: January 2019

Education and expertise in airway skills are central components of anaesthesia training, yet there is no formal monitoring of the airway experience or level of competence that registrars actually obtain. An audit was performed in two phases to prospectively document the airway management experience of registrars in one teaching hospital department. Novices were studied for three months and subsequently, the whole registrar group for one month. Novice registrars performed a mean of two facemask anaesthetics, 19 laryngeal mask airways and 20 endotracheal intubations per month in their first three months of anaesthetic practice. The overall registrar group performed a mean of 18 laryngeal mask airways and 19 endotracheal intubations in the study month. Our findings indicate that the airway experience of anaesthesia trainees may be inadequate and therefore warrants further investigation.
Alpha1-adrenergic Receptor mRNA and Inflammatory Mediator Expression in Circulating Leucocytes after Cardiac Surgery
Authors: Kalkoff M. , Chan-dominy A. , Sleigh J. W. , Jogia P. M. , Cursons R. T. , Towers R. , La Pine M.
Published: January 2019

Vasodilation after coronary artery bypass surgery is a common complication. Inflammatory mediators influence the expression of alpha 1-adrenergic receptors. Do patients requiring high doses of postoperative inotropic support have down-regulated alpha-adrenergic receptors'? Is there a characteristic pattern of preoperative inflammatory mediator expression that could predict a complicated course after the operation?

Forty-four patients undergoing cardiac bypass surgery with extracorporeal circulation were prospectively investigated. Five perioperative blood samples were taken (preoperative, two hours, 12 hours, 36 hours and 72 hours postoperative). The leucocyte mRNA-expression of the three alpha 1-adrenergic receptor subtypes (A, B and D) and 11 different pro-inflammatory mediators were investigated with the real-time reverse transcriptase polymerase chain reaction. The patients were divided into three groups (No-noradrenaline [No-NA]=0 μg/min, Low-noradrenaline [Low-NA]=0.1-7 μg/min, High-noradrenaline [High-NA] >7 ixglmin), according to their postoperative noradrenaline requirements. Preoperatively, alpha 1A-receptor expression was 4.9-fold (High-NA) and 18.7-fold (Low-NA) higher than the No-NA group (P=0.005) and plasma noradrenaline levels were higher in the High-NA group (P=0.005). Across all groups at 12 hours after the operation, alpha 1A-receptor expression decreased to approximately one-fifth of preoperative levels (P=0.01); but with greater duration and magnitude of relative decrease in the High-NA group. Patients in the No-NA group had significant postoperative increases in leucocyte inflammatory mediator expression for IL-1β, TLR4, TREM, MPO, MMP9 and TNF genes, whereas the changes in the Low-NA and High-NA groups were not significant.

Low preoperative levels of noradrenaline and low expression of alpha 1A-adrenoreceptors in leucocytes was associated with less probability of requiring noradrenaline support after cardiac surgery.
Relative Reliability of the Auditory Evoked Potential and Bispectral Index for Monitoring Sedation Level in Surgical Intensive Care Patients
Authors: Lu C.-H. , Ou-yang H.-Y. , Man K.-M. , Hsiao P.-C. , Ho S.-T. , Wong C.-S. , Liaw W.-J.
Published: January 2019

Sedation is an important adjunct therapy for patients in the intensive care unit. The objective of the present study was to observe correlation between an established subjective measure, the Ramsay Sedation Scale, and two objective tools for monitoring critically ill patients: the Bispectral Index (BIS) and auditory evoked potential. Ninety patients undergoing major surgery scheduled for postoperative mechanical ventilation and continuous sedation with propofol and fentanyl were selected. Electrodes for determining BIS and auditory evoked potential were placed on the foreheads of all patients according to manufacturer's specifications at least six hours after patients’ arrival at the intensive care unit. Ramsay Sedation Scale, BIS, signal quality index, composite A-line autoregressive index (AAI) and electromyographic activities were recorded every five minutes for 30 minutes. BIS and AAI showed good correlation amongst readings (rs=0.697, P <0.07). Both were significantly influenced by electromyographic activities (BIS, rs=0.735, P <0.07; AAI, rs=0.856, P <0.07). Comparison of BIS and AAI revealed an acceptable correlation between electroencephalogram variables and the Ramsay Sedation Scale (BIS, τ=-0.689; AAI, τ=-0.621; P <0.07). In conclusion, the auditory evoked potential and BIS monitors revealed an acceptable correlation with the Ramsay Sedation Scale. However, the BIS and auditory evoked potential monitors do not perform adequately as a substitute in the assessment of sedated intensive care unit patients. These monitors could be used as part of an integrated approach for the evaluation of those patients especially when the subjective scales do not work well in the setting of neuromuscular blockade or may not be sufficiently sensitive to evaluate very deep sedation.
A Comparison of Screen-based Simulation and Conventional Lectures for Undergraduate Teaching of Crisis Management
Authors: Tan G. -M. , Ti L. K. , Tan K. , Lee T.
Published: January 2019

In our institution, we introduced a screen-based simulator to our undergraduate lectures on medical crisis management. We hypothesised that this novel use of the screen-based simulator would be as effective as our conventional lectures. To test this we randomly divided medical students into two groups. Students in Group A were taught medical crisis management (heart failure and anaphylaxis) using a screen-based simulation program projected onto a shared screen, with a facilitator guiding the students through the scenarios. Simultaneously, students in Group B were lectured the same content without the screen-based simulation. Both groups were allotted exactly one hour. Several days later, students were tested on their management of anaphylaxis using the Human Patient Simulator. A blinded marker assessed them on diagnosis, resuscitation, specific treatment, call for help and for reassessment of the patient. Students also answered a questionnaire on their experience. Sixty-four students participated in the study. Both groups had similar overall scores. However, students in Group A scored better in the specific treatment category by a factor of 7.7. Students in both groups rated their learning experiences highly. This study showed that screen-based simulation was as effective as conventional lectures and might be even more effective in some areas.
Fatal Vitamin C-associated Acute Renal Failure
Authors: Mchugh G. J. , Graber M. L. , Freebairn R. C
Published: January 2019

Although daily ingestion of high-dose vitamin C is generally regarded as largely innocuous, fatal nephrotoxicity can occur in some rare circumstances. We report a case where the patient, who chose to forgo any advanced conventional medical intervention (dialysis and mechanical ventilation), had failed to disclose his use of high-dose vitamin C and subsequently died. Intra-renal oxalate crystal deposition was demonstrated at autopsy. Directed enquiry with the family then revealed his high-dose vitamin C usage. Even though fully-informed discussion was limited by incomplete prospective disclosure, it remains the prerogative of any competent patient to decline any treatment, including those that may be considered life-saving.
Sequential Organ Failure Assessment Score and Comorbidity: Valuable Prognostic Indicators in Chronically Critically Ill Patients
Authors: Lee K. , Hong S. B. , Lim C. M. , Koh Y.
Published: January 2019

Chronically critically ill patients are defined as those who survive initial life-threatening, possibly reversible organ failure(s) but are unable to recover rapidly to a point at which they are fully independent of life support. Accordingly, these patients require mechanical ventilation and medical resources for a long time in an intensive care unit (ICU). The present study analysed demographic, clinical and survival data of chronically critically ill patients, to identify condition(s) related to poor prognosis. A total of 141 chronically critically ill patients were studied retrospectively over a two-year period (July 1, 2003 to June 30, 2005). Their mean lengths of stay in the ICU and in the hospital were 42.9±36.4 and 83.9±100.5 days respectively. ICU and six-month cumulative mortality rates were 42.6% and 75.9% respectively. Non-survivors had a significantly higher Sequential Organ Failure Assessment (SOFA) score than survivors on day 21 of ICU admission, as well as having significantly lower changes of SOFA scores between days three and 21. Multivariate analysis demonstrated that the SOFA score on day 21 and the Charlson Comorbidity Index were the best predictor of survival for six months after hospital discharge. The SOFA score on day 21 and comorbidity in the ICU appears to be a valuable prognostic indicators in chronically critically ill patients.
Sedation and Delirium in the Intensive Care Unit: An Australian and New Zealand Perspective
Authors: Shehabi Y. , Botha J. A. , Boyle M. S. , Ernest D. , Freebairn R. C. , Jenkins I. R. , Roberts B. L. , Seppelt I. M.
Published: January 2019

A survey was conducted to determine sedation and delirium practices in Australian and New Zealand intensive care units.

The survey was in two parts, comprising an online survey of reported sedation and delirium management (unit survey) and a collection of de-identified data about each patient in a unit at a given time on a specified day (patient snapshot survey). All intensive care units throughout Australia and New Zealand were invited by email to participate in the survey.

Twenty-three predominantly metropolitan, level III Australian and New Zealand intensive care units treating adult patients participated. Written sedation policies were in place in 48% of units, while an additional 44% of units reported having informal sedation policies. Seventy percent of units routinely used a sedation scale. In contrast, only 9% of units routinely used a delirium scale. Continuous intravenous infusion is the primary means of patient sedation (74% of units). While 30% of units reported routinely interrupting sedation, only 10% of sedated patients in the snapshot survey had had their sedation interrupted in the preceding 12 hours. Oversedation appears to be common (46% of patients with completed sedation scales). Use of neuromuscular blockade is low (10%) compared to other published studies. Midazolam and propofol were the most frequently used sedatives. The proportion of patients developing delirium was 21% of assessable patients. Failed and self-extubation rates were low: 3.2% and 0.5% respectively.

In Australian and New Zealand intensive care units, routine use of sedation scales is common but not universal, while routine delirium assessment is rare. The use of a sedation protocol is valuable and should be encouraged.
Dr Corlette and the First Textbook of Regional Anaesthesia in Australia
Authors: Cooper M. G. , Corlette T.
Published: January 2019

The first Australian textbook on regional anaesthesia was published in 1948 by a surgeon, Dr Cyril Corlette. He was 80 years old at the time but had lectured, published and strongly promoted regional anaesthesia his whole career. He was a renowned teacher and a Founder of the Royal Australasian College of Surgeons. He also published controversial work on heat loss under anaesthesia and anaesthetic mortality. This textbook, “A Surgeon's Guide to Local Anaesthesia”, subtitled “A Manual of Shockless Surgery”, helped to promote the concept of regional anaesthesia in Australia.
The Origins of the Sniffing Position and the Three Axes Alignment Theory for Direct Laryngoscopy
Authors: Greenland K. B. , Eley V. , Edwards M. J. , Allen P. , Irwin M. G.
Published: January 2019

The Three Axes Alignment Theory and the sniffing position for direct laryngoscopy are the anatomical basis for direct laryngoscopy. This position has been one of the hallmarks of airway management and yet its development is based on a small number of descriptive texts published between 1852 and 1944. This paper explores the origins of direct laryngoscopy and how the sniffing position came to be described. The seemingly incongruent techniques of the rigid bronchoscopist and direct laryngoscopist are discussed from an historical perspective.
The Bonnievale Disaster of 1907
Authors: Mcglew I.C.
Published: January 2019

In a museum at the Coolgardie Railway Station, Western Australia, a most unusual piece of equipment is exhibited. On display is diving gear which was used in a dramatic rescue attempt from a flooded mine just over a hundred years ago. The rescue of the trapped miner rates as an epic in Australian mining history, alongside that of two miners in Beaconsfield, Tasmania, in 2006.
Occupational Health and Safety in Medical Museums
Authors: Westhorpe R. N.
Published: January 2019

Medical museum collections provide challenges in occupational health and safety that do not become apparent in many other collections. During the recent development of the Geoffrey Kaye Museum of the Australian and New Zealand College of Anaesthetists, these challenges were addressed, following the guidelines of the Occupational Health and Safety Regulations of the State of Victoria. This paper details these regulations and their necessary application in this specialist museum.
Patient Sex and its Influence on General Anaesthesia
Authors: Buchanan F. F. , Myles P. S. , Cicuttini F.
Published: January 2019

Physiological and pharmacological differences exist between men and women. Women wake faster than men following general anaesthesia. Women also differ from men in their postoperative recovery as reflected by differences in postoperative pain, nausea and vomiting and overall quality of recovery. These gender differences seem to be more pronounced in premenopausal women, suggesting hormonal mechanisms are a major contributing factor.
Intraoperative Ketamine may Influence Persistent Pain following Knee Arthroplasty under Combined General and Spinal Anaesthesia: A Pilot Study
Authors: Perrin S. B. , Purcell A. N.
Published: January 2019

We report the findings of a randomised controlled triple-blind pilot study of intraoperative ketamine infusion combined with spinal anaesthesia on the prevalence of persisting post surgical pain following total knee arthroplasty surgery. Twelve patients were randomised to receive either ketamine or placebo in association with spinal anaesthesia for total knee arthroplasty. All patients also received general anaesthesia. More patients were pain-free at six months in the ketamine group (three of five) compared to the control group (two of seven). Perioperative data collected during the study suggested that the addition of intraoperative ketamine might also improve the quality of recovery. Although no statistical analysis was undertaken due to the small numbers, these preliminary findings suggest that the use of intraoperative systemic ketamine in association with spinal anaesthesia for the reduction of persisting post surgical pain deserves further study.
Fibreoptic Intubation under General Anaesthesia – a Simple Method Using an Endotracheal Tube as a Conduit
Authors: Cumpston P. H. V
Published: January 2019

A novel technique for management of the difficult airway is described. The case report describes fibreoptic intubation of a patient who refused awake intubation. An endotracheal tube was advanced as far as the nasopharynx via the nostril of the patient, under anaesthesia. Connection of the anaesthetic circuit allowed maintenance of anaesthesia, oxygenation and assisted ventilation while flexible bronchoscopy was performed through the tube via a bronchoscopy connector. The endotracheal tube was subsequently advanced over the bronchoscope into the trachea. This technique uses readily available materials and can be used where the placement of a laryngeal mask is contraindicated or impossible.
A Patient with Intractable Posthypoxic Myoclonus (Lance-Adams Syndrome) Treated with Sodium Oxybate
Authors: Arpesella R. , Dallocchio C. , Arbasino C. , Imberti R. , Martinotti R. , Frucht S. J.
Published: January 2019

Posthypoxic myoclonus is a rare and devastating complication of near-fatal cardiopulmonary arrest. Despite treatment with available anti-myoclonic agents, some patients may recover cognitively but remain completely disabled by severe myoclonus. We report a 16-year-old patient with severe treatment-refractory posthypoxic myoclonus, which improved markedly with administration of the drug sodium oxybate.
Diabetes Insipidus following Overdose of Baclofen and Quetiapine
Authors: Silversides J. A. , Scott K. C.
Published: January 2019

We report the case of a patient who presented with coma in the context of baclofen and quetiapine overdose. While the clinical picture was largely in keeping with previous descriptions of baclofen and quetiapine toxicity, the patient went on to exhibit clinical and biochemical features of cranial diabetes insipidus, a finding which has not previously been described in this context.
Remifentanil-Induced Abdominal Pain: A Randomised Clinical Trial
Authors: Jahanbakhsh S. , Bameshki A. , Khashayar P.
Published: January 2019

Remifentanil is an ultra-short-acting opioid, widely used for induction and maintenance of anaesthesia in various types of operations. We recently noted that a great number of patients receiving remifentanil in their anaesthetic regimen experienced postoperative abdominal pain. As a result, we performed this study to investigate its incidence.

This randomised single-blinded clinical trial was conducted on 300 patients who were undergoing elective cataract surgery under general anaesthesia. The patients were randomly divided into two groups. In the control group (n=150), anaesthesia was induced with fentanyl and propofol and maintained with propofol by infusion and 60% N2O. In the remifentanil group, anaesthesia was induced with remifentanil and propofol and maintained with remifentanil infusion and inhalation of 60% N2O. Atracurium was used for muscle relaxation in both groups.

Abdominal pain was observed in 79 patients (52.6%) in the remifentanil group, 10 of whom required a therapeutic intervention, but in only three patients in the control group, none of whom required an intervention (P value = 0.001). Postoperative nausea and vomiting were reported in seven and 10 patients (4.7%) in the remifentanil and control group, respectively.

These findings indicate that abdominal pain is very common in patients receiving remifentanil by infusion for cataract surgery.
Creutzfeldt-Jakob Disease – Implications for Anaesthetists in New Zealand
Authors: Telfer J. M.
Published: January 2019

Since 1996 with the recognition of a variant form, Creutzfeldt-Jakob disease has become more prominent in the medical literature. Of particular interest to anaesthetists is the risk of iatrogenic spread of the disease.

In this article, the relevant literature is reviewed and the experience within New Zealand examined. The presentation, pathology and incidence of the disease is reviewed and the current guidelines for the preoperative management of patients with known or suspected Creutzfeldt-Jakob disease are outlined.
Continuous Spinal Analgesia after Extensive Lumbar Spine Surgery
Authors: Mckenzie A. , Sherwood M.
Published: January 2019

A 77-year-old male underwent L-1 to S-1 spine decompression and fusion from L-3 to S-1. A 25 G spinal catheter was placed intraoperatively and bupivacaine 1.25 mg/ml, fentanyl 2 μg/ml and morphine 3 μg/ml infused. The patient was pain-free for the duration of the infusion. Continuous spinal analgesia was effective after extensive spinal surgery. The risks of post-dural puncture headache, infection of wound and/or meninges and the optimum drug doses and combinations are yet to be quantified in this setting.
Laboratory Validation of the M-COVX Metabolic Module in Measurement of Oxygen Uptake
Authors: Stuart-Andrews C. R. , Peyton P. , Walker T. B. , Cairncross A. D. , Robinson G. J. B. , Lithgow B.
Published: January 2019

A practical method of breath-by-breath monitoring of metabolic gas exchange has previously been developed by GE Healthcare and can now be easily incorporated into existing anaesthetic and critical care monitoring (M-COVX). Previous research using this device has shown good accuracy and precision between the M-COVX measurements and a traditional measurement of gas uptake at the mouth and also against the reverse Fick method during cardiac surgery and critical care, but its accuracy in the paediatric situation and across a range of ventilatory settings awaits validation. We tested the M-COVX metabolic monitor in the laboratory comparing its measurement to a traditional Haldane transformation across a wide range of oxygen consumption values, from 50 ml/minute to just under 300 ml/minute, typical of those expected in anaesthetised adults and children. The M-COVX device showed acceptable accuracy with an overall mean bias of −3.3% (range −15.1 to +4.2%, P=0.21). Excellent linearity was found, by y=0.96x + 0.5 ml/minute, r=0.99. The device showed acceptable robustness to ventilatory changes examined, including changes in respiratory rate, I:E ratio, FiO2, up to 75% and simulated spontaneous breathing. However, any induced leak from around the simulated endotracheal tube caused a significant error in paediatric scenarios.
A Comparison of Eosinopenia and C-Reactive Protein as a Marker of Bloodstream Infections in Critically Ill Patients: A Case Control Study
Authors: Ho K. M. , Towler S. C.
Published: January 2019

Diagnosis of bloodstream infections in critically ill patients is difficult. This case control study involved a total of 22 patients with confirmed bloodstream infections and 44 concurrent controls from an intensive care unit in Western Australia. We aimed to assess whether eosinopenia and C-reactive protein are useful markers of bloodstream infections in critically ill patients. The patients with bloodstream infections had a more severe disease and a longer length of intensive care unit (10.7 vs 4.0 days, P=0.001) and hospital stay (40.9 vs 17.9 days, P=0.015) than the controls. Univariate analyses showed that C-reactive protein (area under the receiver operating characteristic curve 0.847, 95% confidence internal (CI) 0.721 to 0.973), eosinophil counts (area under the receiver operating characteristic curve 0.849, 95% CI 0.738 to 0.961) and fibrinogen concentrations (area under the receiver operating characteristic curve 0.730, 95% CI 0.578 to 0.882) were significant markers of bloodstream infections. C-reactive protein concentration was, however, the only significant predictor in the multivariate analysis (odds ratio 1.21 per 10 mgH increment, 95% CI 1.01 to 1.39, P=0.007). C-reactive protein concentration appears to be a better marker of bloodstream infections than eosinopenia in critically ill patients. A large prospective cohort study is needed to assess whether eosinopenia is useful in addition to C-reactive protein concentrations as a marker of bloodstream infections.
The Functional Outcome and Recovery of Patients Admitted to an Intensive Care Unit following Drug Overdose: A Follow-Up Study
Authors: O'Brien B. P. , Murphy D. , Conrick-Martin I. , Marsh B.
Published: January 2019

Patients who have overdosed on drugs commonly present to emergency departments, with only the most severe cases requiring intensive care unit (ICU) admission. Such patients typically survive hospitalisation. We studied their longer term functional outcomes and recovery patterns which have not been well described.

All patients admitted to the 18-bed ICU of a university-affiliated teaching hospital following drug overdoses between 1 January 2004 and 31 December 2006 were identified. With ethical approval, we evaluated the functional outcome and recovery patterns of the surviving patients 31 months after presentation, by telephone or personal interview. These were recorded as Glasgow outcome score, Karnofsky performance index and present work status.

During the three years studied, 43 patients were identified as being admitted to our ICU because of an overdose. The average age was 34 years, 72% were male and the mean APACHE II score was 16.7. Of these, 32 were discharged from hospital alive. Follow-up data was attained on all of them. At a median of 31 months follow-up, a further eight had died. Of the 24 surviving there were 13 unemployed, seven employed and four in custody. The median Glasgow outcome score of survivors was 4.5, their Karnofsky score 80.

Admission to ICU for treatment of overdose is associated with a very high risk of death in both the short- and long-term. While excellent functional recovery is achievable, 16% of survivors were held in custody and 54% unemployed.
Inflammation, Vitamin Deficiencies and Organ Failure in Critically Ill Patients
Authors: Corcoran T. B. , O'Neill M. P. , Webb S. A. R. , Ho K. M.
Published: January 2019

It is unknown whether biochemical vitamin deficiencies in critical illness are associated with severity of illness, organ dysfunction, inflammation or mortality. This nested cohort study recruited 98 patients admitted as emergencies to the intensive care unit, who had a stay of greater than 48 hours. Patient data were prospectively collected. Within the first 48 hours of admission, concentrations of C-reactive protein, vitamins A, E, B1, B12 and folate were measured on arterial blood. These measures were then repeated at least once during the later (>48 hours) period of their stay. Seventy patients (71%) had completed vitamin studies eligible for inclusion in the analysis. Ten patients died (14.3%) during their hospital stay and mortality was associated with age, admission source and severity of illness scores. Vitamin B12 concentration was weakly associated with C-reactive protein concentrations on admission to the intensive care unit (r on days one and two=0.4 [P=0.002], 0.36 [P=0.04], respectively) and with the Sequential Organ Failure Assessment score between days two and four (Spearman's r=0.361 [P=0.04], 0.42 [P=0.02] and 0.48 [P=0.02], respectively). Vitamin A concentration was weakly associated with the C-reactive protein concentrations on days one and five (Spearman's r=-0.5 [P=0.001], −0.4 [P=0.03], respectively). Change in deficiency status of any of the vitamins over time in the first week of intensive care admission did not appear to influence mortality. We conclude that while weak correlations were identified between vitamins A and B12 and C-reactive protein and Sequential Organ Failure Assessment scores, the importance of these associations and their relationship to hospital mortality remain to be determined.
Effect of Pump Prime on Acidosis, Strong-ion-difference and Unmeasured Ions during Cardiopulmonary Bypass
Authors: Liskaser F. , Story D. A. , Hayhoe M. , Poustie S. J. , Bailey M. J. , Bellomo R.
Published: January 2019

We tested the hypothesis that a cardiopulmonary bypass prime with lactate would be associated with less acidosis than a prime with only chloride anions because of differences in the measured strong-ion-difference. We randomised 20 patients to a 1500 ml bypass prime with either a chloride-only solution (Ringer's Injection; anions: chloride 152 mmol/l) or a lactated solution (Hartmann's solution; anions: chloride 109 mmol/l, lactate 29 mmol/l). Arterial blood was sampled before bypass and then two, five, 15 and 30 minutes after initiating bypass. We used repeated measures analysis of variance to compare groups. In both groups, the base-excess and measured strong-ion-difference decreased markedly from baseline after two minutes of bypass. The chloride-only group had greater acidosis with lower base-excess and pH (P <0.05), greatest after five minutes of bypass (C5). Contrary to our hypothesis, however, the difference between the groups was not due to a difference in the measured strong-ion-difference, P=0.88. At C5 when the difference in standard base-excess between the groups was greatest, 1.9 mmol/l (95% confidence interval: 0.1 to 3.6 mmol/l, P <0.05), the difference in the measured strong-ion-difference was only 0.2 mmol/1 (95% confidence interval: −2.4 to 2.7 mmol/l, P >0.05). There was, however, a difference in the net-unmeasured-ions (strong-ion-gap). We conclude that acid-base changes with cardiopulmonary bypass may differ with the prime but that the early differences between chloride-only and lactated primes appear not to be due to differences in the measured strong-ion-difference. We suggest future studies examine other possible mechanisms including unmeasured ions.
The Performance of Customised APACHE II and SAPS II in Predicting Mortality of Mixed Critically Ill Patients in a Thai Medical Intensive Care Unit
Authors: Khwannimit B. , Bhurayanontachai R.
Published: January 2019

The aim of this study was to evaluate and compare the performance of customised Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score II (SAPS II) in predicting hospital mortality of mixed critically ill Thai patients in a medical intensive care unit. A prospective cohort study was conducted over a four-year period. The subjects were randomly divided into calibration and validation groups. Logistic regression analysis was used for customisation. The performance of the scores was evaluated by the discrimination, calibration and overall fit in the overall group and across subgroups in the validation group. Two thousand and forty consecutive intensive care unit admissions during the study period were split into two groups. Both customised models showed excellent discrimination. The area under the receiver operating characteristic curve of the customised APACHE II was greater than the customised SAPS II (0.925 and 0.892, P <0.001). Hosmer-Lemeshow goodness-of-fit showed good calibration for the customised APACHE II in overall populations and various subgroups but insufficient calibration for the customised SAPS II. The customised SAPS II showed good calibration in only the younger, postoperative and sepsis patients subgroups. The overall performance of the customised APACHE II was better than the customised SAPS II (Brier score 0.089 and 0.109, respectively). Our results indicate that the customised APACHE II shows better performance than the customised SAPS II in predicting hospital mortality and could be used to predict mortality and quality assessment in our unit or other intensive care units with a similar case mix.