bluuebunny/crossref_metadata_2025 huggingface dataset:
Anaphylaxis to Suxamethonium—A Case Report
Authors: Matthews M. D. , Ceglarski J. Z. , Pabari M.
Published: January 2019

A case history is presented of a woman who developed very severe bronchospasm, hypotension, “lobster-red “erythema and later angio edema of the head and neck after induction of anaesthesia for caesarean section. Intradermal testing at a later date, showed immediate-type sensitivity to suxamethonium. Reference is made to the other few reactions to suxamethonium reported in the world literature.
Irreversible Curarization
Authors: Baraka Anis
Published: January 2019

The reversal effect of neostigmine following different doses of tubocurarine was investigated in 20 anesthetized adults.

After five minutes, neostigmine could rapidly and effectively reverse a blocking dose of tubocurarine. Doubling the dose of tubocurarine necessitated a much higher concentration of neostigmine to achieve reversal, while a triple dose could be reversed only after enough time had elapsed to allow for lowering its concentration.

It is concluded that the degree of reversal by neostigmine is related inversely to the concentration of tubocurarine at the time of reversal. An overdose of tubocurarine predisposes to the so called “neostigmine-resistant curarization”.
A Scavenging Device for the T-Piece
Authors: Keneally J. P. , Overton J. H.
Published: January 2019

An inexpensive and convenient method of collecting waste gases from the open-tailed bag of a T-piece system is described.
Ed50 Values for Thiopentone, Methohexital Propanidid and Alfathesin: A Clinical Experiment
Authors: Crankshaw D. P. , Allt-Graham J.
Published: January 2019

A cumulative dose response curve for loss of consciousness was obtained using 48 unselected premedicated patients presenting for elective surgery. Dosage was administered on the basis of lean tissue mass (LTM) using a simple nomogram. The end point for loss of consciousness was the failure of the patient to grasp a light object. Using probit analysis an ED50 for thiopentone in premedicated patients was found to be 2.63 mg/kg LTM. The sequential up-and-down technique was then used to determine ED50 values for thiopentone (2.70 mg/kg LTM), methohexitone (1.1 mg/kg LTM), propanidid (3.66 mg/kg LTM) and Alfathesin (0.014 ml/kg LTM).

The experimental methods and, in particular, the administration of doses to patients on the basis of LTM, would appear to be responsible for a high level of predictability of response in an apparently heterogeneous patient population.

The ED50 values compared favourably with clinically recommended doses for induction of anaesthesia, except the ED50 for Alfathesin which was approximately one quarter of that recommended.

An appendix provides some of the mathematical background of the up-and-down sequential technique together with a table of maximum likelihood solutions for different sequences and an example of the calculation of an ED50 and its confidence limits
Radial Artery Cannulation: Influence of Catheter Size and Material on Arterial Occlusion
Authors: Davis F. M.
Published: January 2019

A randomized, prospective trial of four different cannulae used for percutaneous radial artery cannulation was carried out in one hundred and forty-eight patients undergoing cardiopulmonary bypass surgery. Arterial occlusion was assessed using a modified Allen's test and an ultrasonic flow monitor. The incidence of complete occlusion eight days after decannulation was 34% for 18-gauge polypropylene and 0% for 20-gauge Teflon cannulae. Both the size and material of the cannula are important factors in the occurrence of arterial occlusion. This complication can largely be eliminated by the use of small Teflon cannulae.
A Comparison between Ketamine and Diazepam as Induction Agents for Pericardiectomy
Authors: Kingston H. G. G. , Bretherton K. W. , Holloway A. M. , Downing and J. W.
Published: January 2019

Ketamine 1 · 0 mg/kg and diazepam 0 · 3 mg/kg was used to induce anaesthesia in patients requiring pericardiectomy. A significant rise in blood pressure in patients receiving ketamine was noted. In contrast, a fall in blood pressure was seen when diazepam was administered. Changes in cardiac output, cardiac index, central venous pressure and systemic vascular resistance are discussed.

Ketamine appears to be a more satisfactory agent for induction of anaesthesia in patients for pericardiectomy, whereas diazepam should be used with caution.
Case Report: High Sympathetic Block with Ptosis after Lumbar Epidural Analgesia in an Obstetric Patient
Authors: Sprigge J. S.
Published: January 2019

Following lumbar epidural analgesia, a 26 year old primigravida developed right ptosis and other signs of paralysis of the right sympathetic supply to the head and neck. The case is discussed and compared with cases of Horner's syndrome which have followed epidural analgesia. It was probably due to differential sympathetic blockade.
Case Report: Barbiturate Administration during Technically Difficult Carotid Artery Surgery
Authors: McMeniman W. J. , Hicks R. G.
Published: January 2019

A case report illustrating possible cerebral protection from ischemia by barbiturate administration during carotid artery surgery where bypass shunting was indicated from the EEG recording but technically impossible to achieve.
A Real-Time On-Line Digital Computer Method for Monitoring Myocardial Supply: Demand Ratio
Authors: Wood S. L. , Crosby P. A.
Published: January 2019

The Myocardial Supply: Demand Ratio reflects the ratio of subendocardial perfusion to subendocardial oxygen demands. A method is described for calculating and continuously monitoring the Myocardial Supply: Demand Ratio using a digital computer in real-time.
Technical Aspects of Bronchopulmonary Lavage for Alveolar Proteinosis: Two Case Reports
Authors: Harrison G. A. , Kelly A. J.
Published: January 2019

Under general anaesthesia, therapeutic bronchopulmonary lavage was performed in two patients suffering from alveolar proteinosis. In one patient, difficulties were experienced during attempted lavage of the right lung. Fluid trapping occurred when saline was infused down the tracheal (right) lumen of a Carlen's double lumen endobronchial tube and also when a left Robertshaw tube was similarly used. Spillover of saline into the left lung occurred when a right Robertshaw was used. Efficient lavage of the right lung could only be performed after insertion of a White endobronchial tube.

In the second patient, both lungs were washed without problem using a left Robertshaw tube after difficulty had been experienced with a Carlen‘s tube.

In both cases venous admixture was least when the lavaged lung was filled with saline. Hypoxaemia increased as the lung was drained. Details of technique are discussed as are problems with double lumen endobronchial tubes used during the procedure.
Atropine and Glycopyrrolate: Changes in Cardiac Rate and Rhythm in Conscious and Anaesthetised Children
Authors: Mirakhur R. K. , Jones C. J.
Published: January 2019

Heart rate and rhythm were studied in conscious children and children under nitrous oxide and halothane anaesthesia following intravenous administration of atropine or glycopyrrolate. Both drugs produced a similar increase in heart rate when the potency of glycopyrrolate is considered twice that of atropine. There is no difference in the response of anaesthetised and awake children. Junctional rhythm is the main dysrhythmia observed which appears to occur more frequently in anaesthetised children. The administration of both drugs is safe in paediatric patients.
Midazolam for the Intravenous Induction of Anaesthesia in Children
Authors: Holloway A. M. , Jordaan D. G. , Brock-Utne J. G.
Published: January 2019

Midazolam was compared with thiopentone as an intravenous anaesthetic induction agent in children between four and twelve years of age undergoing elective minor surgical procedures. Successful induction of anaesthesia was achieved in both groups of patients. With midazolam induction time was longer than with thiopentone, but the difference was not statistically significant. The incidence of apnoea was greater with thiopentone, but not significantly so. It is concluded that midazolam is effective and safe, and could prove a reasonable alternative to thiopentone as an intravenous induction agent in children undergoing elective minor operations.
The Management of Headache following Accidental Dural Puncture in Obstetric Patients
Authors: Brownridge Peter
Published: January 2019

The progress and management of fifty-eight obstetric patients who received an accidental dural puncture is described. Headache attributable to dural puncture occurred in 85% of patients managed conservatively. Epidural infusion or repeat epidural bolus injections of saline after delivery reduced the incidence to 65%. A therapeutic autologous blood patch using 8-10 ml of blood was performed in 28 patients at least 24 hours after the accidental puncture. Dramatic and permanent relief occurred in 75% following this procedure. A repeat blood patch was effective in four patients, and ineffective in the remaining two. Mild and temporary back stiffness and one case of moderately severe radicular pain for three days were the only complications noted after the procedure.

The pathophysiology and treatment of dural puncture headache is reviewed. Reduction of pressure differential across the dural puncture site is most useful in the first 24-48 hours. Persistent and severe headache occurring after this should be treated with blood patch.
Plasma Bupivacaine Concentrations in Children during Caudal Epidural Analgesia
Authors: Eyres R. L. , Bishop W. , Oppenheim R. C. , Brown T. C. K.
Published: January 2019

Plasma bupivacaine concentrations were measured in 45 children, whose ages ranged from 4 months to 12 years, following administration of caudal epidural analgesia. Using 3 mg/kg of bupivacaine 0.25%, mean blood levels of 1.2-1.4 μg/ml were reached, which are well within the limits of projected toxic levels. Simultaneous arterial and venous sampling showed a small but significant difference between these two sampling sites for the first fifteen minutes.
Plasma Lignocaine Concentrations following Topical Laryngeal Application
Authors: Eyres R. L. , Bishop W. , Oppenheim R. C. , Brown T. C. K.
Published: January 2019

Lignocaine 4%, 4 mg/kg, was sprayed onto the larynx and subglottic area of 96 children aged from 2 weeks to 12 years and plasma lignocaine concentrations were measured. While the majority were well within the accepted safe range (4-5 μg/ml) occasional concentrations over 8 μg/ml appeared in all groups. Simultaneous arterial and venous sampling showed a small but significant difference in the first 10 minutes.
Acute Stress Ulceration
Authors: Hillman K.
Published: January 2019

Stress ulceration is usually considered a mucosal abnormality of the oesophagus, stomach or duodenum in the critically ill. It is found to a varying degree in all such patients. Only about one-quarter of lesions are associated with blood loss and less than 5% need resuscitation and treatment. However, because treatment of established bleeding is unsatisfactory, and associated with a high mortality, prophylactic measures are usually employed. These include optimising gastric mucosal blood flow and oxygen delivery, correcting coagulation abnormalities and treating underlying infection. Enteral feeding should also be employed whenever possible. Other prophylactic measures currently used involve raising gastric pH above 4, with either antacids or H2 receptor antagonists. This is best achieved by measuring the gastric pH hourly and titrating it against an appropriate dose of either type of drug or a combination of both. Newer drugs, such as omeprazole, sucralfate and prostaglandins, are proving very successful in the treatment and prevention of gastric and duodenal ulcers and may prove even more effective than currently available agents.
Acute Pancreatitis
Authors: Thomas P. D.
Published: January 2019

This paper provides a review of recent advances in the understanding and management of acute pancreatitis. The mortality of acute severe pancreatitis remains disappointingly high. While there have been relatively few recent advances in the surgical management of acute pancreatitis, several nonsurgical developments appear promising.
Reduction of Heat Loss during Transurethral Resection of the Prostate
Authors: Dyer P. M. , Heathcote P. S.
Published: January 2019

A prospective trial was performed on 100 patients to determine whether using a reflective blanket (Space Blanket) and heated glycine 1.5% bladder irrigation solution would decrease the fall in body temperature associated with transurethral resection of the prostate under spinal anaesthesia. Patients who received a combination of reflective blanket and heated glycine 1.5% solution had their fall in body temperature significantly reduced when compared with those patients managed without a reflective blanket and/or heated 1.5% glycine.

There was a marked decrease in the number of patients shivering and no increase in blood loss was seen when heated bladder irrigation solution was used.
Alfentanil for Short Duration Laparoscopic Procedures
Authors: Lee K. S. , Purcell G. J. , Rae B. R. , White B.
Published: January 2019

Alfentanil in low dosage (8 μg kg−1) as an analgesic agent for short duration surgery was evaluated. Forty-one women undergoing laparoscopy received double-blind either alfentanil 8 μg kg−1 or normal saline at induction, and all received thiopentone, alcuronium, enflurane, nitrous oxide and oxygen.

The fall in mean arterial pressure (MAP) with induction was similar between groups.

The MAP following intubation with alfentanil was unchanged, while with normal saline a mean rise of 23 (SD 15.2) mmHg occurred (P<0.001). The pulse rate following intubation showed a smaller rise (P<0.001) with alfentanil of 26 (SD 14.6) beats min−1, than the normal saline group of 46 (SD 13.3) beats min−1. Alfentanil was found to be a safe and effective analgesic agent in short duration surgery, by reducing sympathetic responses to intubation without cardiovascular depression or compromise of postoperative recovery.
The Role of Pharmacokinetics in Anaesthesia: Application to Intravenous Infusions
Authors: Stanski D. R.
Published: January 2019

Pharmacokinetic concepts describe the relationship between drug dose and resulting plasma concentration. A drug's pharmacokinetic profile can be described by distribution and elimination half-lives, initial volume of distribution, steady-state distribution volume, and metabolic and distributional clearance. After initiating a fixed rate of drug infusion, four to five terminal elimination half-lives are required to reach a steady state of constant plasma concentration. If a loading dose is given, a steady state can be achieved more rapidly. The most rapid method of achieving a constant plasma concentration involves using a variable rate of drug infusion that adjusts for the metabolic clearance and distribution of the drug. Computer-driven infusion pumps can be used to rapidly achieve, then maintain, constant plasma concentrations of a drug.
Hypnotics in Infusion Anaesthesia — with Particular Reference to Thiopentone
Authors: Crankshaw D. P.
Published: January 2019

Hypnotics are a group of drugs whose primary action is to produce unconsciousness. This contrasts to the opioids whose primary action is to reduce the sensation of pain and the tranquillisers whose primary action is to calm and to attenuate psychotic disease. Hypnotics of interest to the anaesthetist are the inhalational agents and intravenously administered drugs, including the barbiturates thiopentone and methohexitone, chlormethiazole, etomidate and propofol. Knowledge of the use of hypnotics to maintain anaesthesia is largely confined to the volatile anaesthetic agents, while knowledge of the use of the intravenous hypnotics is largely restricted to their use as intravenous induction agents and as sedatives for regional procedures. The use of intravenous hypnotics to maintain anaesthesia requires careful control of infusion rates based on pharmacokinetic predictions. Once techniques are established, favourable operating conditions can be achieved, as well as acceptably short recovery times. With such techniques, the benefits of freedom from many of the adverse aspects of inhalational anaesthesia can be realised.
Metabolism of Halothane in Children Having Repeated Halothane Anaesthetics
Authors: Plummer J. L. , Steven I. M. , Cousins M. J.
Published: January 2019

Metabolism of halothane was studied in nine children receiving daily halothane anaesthetics (from 10 up to a maximum of 31) over periods of two to seven weeks. Serum bromide concentrations never exceeded 3.5 mmol/l, a concentration below the toxic threshold. Repeated halothane anaesthetics at short intervals did not induce the reductive metabolism of halothane as assessed by 2-chloro-1,1,1-trifluoroethane (CTF) in the expired breath. One patient developed viral hepatitis A during the course of anaesthetic administration; this patient was the only one whose serum bromide concentrations fell substantially and whose exhaled CTF concentration increased as more anaesthetics were administered.
The Effect of Premedication on the Incidence of Postoperative Vomiting in Children after E.N.T. Surgery
Authors: Puttick N. , Van Der Walt J. H.
Published: January 2019

The influence of premedication and intraoperative narcotic administration on the incidence of vomiting after E.N.T. surgery was studied over a six-month period in 596 children. A high incidence of vomiting was found after intramuscular papaveretum and hyoscine and after oral diazepam. Oral trimeprazine tartrate was associated with a low incidence of vomiting and was found to have an anti-emetic effect when an opiate analgesic was administered after induction of anaesthesia.
Anaesthetic-Related Recovery Room Complications
Authors: Zelcer J. , Wells D. G.
Published: January 2019

A prospective survey was conducted over a one-month period in all surgical patients admitted to the recovery room of a university-affiliated teaching hospital. Complications arising in the recovery room were documented by the nursing staff according to predefined criteria and were critically evaluated. A total of 443 patients were admitted to the recovery room and in 133 (30%) of these, some form of complication was noted. There were 86 patients with complications referable to the central nervous system, 68 with abnormal cardiovascular parameters, 24 with nausea and/or vomiting and 10 with abnormalities referable to the respiratory system. Many patients had more than one complication. The results are discussed, with emphasis on their relevance to current anaesthetic practice. It is concluded that many patients exhibit recovery room complications when they are specifically sought. The recovery period remains a time of great potential danger to patients.
A Comparison of Midazolam and Diazepam for Induction of Anaesthesia in High-Risk Patients
Authors: Reitan J. A. , Soliman I. E.
Published: January 2019

Fifty ASA Class III patients were divided randomly into two equal groups for induction of anaesthesia with diazepam 0.25 mg/kg, or midazolam 0.15 mg/kg. All subjects were premedicated with a narcotic and monitored by ECG, radial arterial catheter and a spirometer for measurement of minute ventilation. The QF interval (time period from the Q wave of the ECG to the foot of the radial artery pulse), mean arterial pressure, heart rate and minute ventilation were recorded before, during and immediately after the induction of anaesthesia. Although mean arterial pressure fell slightly (6%) following midazolam, all other cardiovascular variables were stable in both groups. Minute ventilation was depressed to 70% of control by both drugs and nearly one-half the diazepam patients complained of pain on injection compared with only one midazolam patient. These data suggest that midazolam is a reasonable alternative to diazepam for induction of anaesthesia in the high-risk patient.
A Comparison of the Incidence and Nature of Cardiac Dysrhythmias Occurring during Enflurane and Isoflurane Anaesthesia for Dental Surgery
Authors: Rodrigo M. R. C. , Moles T. M. , Lee P. K.
Published: January 2019

The incidence and nature of dysrhythmias with equipotent concentrations of enflurane and isoflurane during dental surgery were compared. Seventy-six Chinese patients between 17–30 years, of ASA Grade I, randomly received either enflurane or isoflurane with N2O and O2 for spontaneous ventilation during third molar extractions. The cardiac rhythm and the blood pressure were continuously monitored during the procedure. The incidence of dysrhythmias with both enflurane and isoflurane was low and the difference not statistically significant. During surgery one patient exhibited unifocal ventricular ectopics with isoflurane. Sinus tachycardia was common with both agents. No life-threatening dysrhythmias were seen with either agent and no clinically significant lowering of blood pressure occurred in association with the exhibited dysrhythmias. In this Chinese population, as in other studies, the incidence of dysrhythmias with both agents was low thus showing no difference between the races.
Halothane in Children with Chronic Liver Disease
Authors: Wark H. , Earl J. , Cooper M. , Overton J.
Published: January 2019

Exacerbation of pre-existing liver disease after halothane anaesthesia has been reported in adult patients. A prospective study was performed in 38 children with biopsy-proven liver disease to assess the effect of surgery and halothane anaesthesia on liver function. Plasma liver enzyme levels were measured immediately pre-operatively and again four to eight days after surgery and halothane anaesthesia. Minor elevations of both AST and ALT occurred in four patients but this was not associated with a clinical deterioration in the patients’ postoperative recovery. In the children studied pre-existing liver disease did not predispose to a deterioration of liver function following surgery and halothane anaesthesia.
Caval Thrombolysis in Neonates Using Low Doses of Recombinant Human Tissue-Type Plasminogen Activator
Authors: Anderson B. J. , Keeley S. R. , Johnson N. D.
Published: January 2019

Four neonates suffered caval thrombosis secondary to indwelling central catheters. Dissolution of thrombus with recombinant tissue plasminogen activator (rt-PA) as a low-dose infusion (0.05 mg/kg/hr) directly into thrombus was successful in three patients. rt-PA was ceased after three days in the fourth patient because of catheter malposition. Thrombolysis was achieved between four and ten days. Rethrombosis occurred in one patient despite heparin prophylaxis. Plasminogen activator infusions were titrated to maintain fibrinogen levels above 100 mg/dl. One neonate suffered an intracranial haemorrhage. Regional rt-PA is an alternative to thrombectomy in critically ill neonates.
Epidural Analgesia in Labour: Constant Infusion plus Patient-Controlled Boluses
Authors: Paech M. J.
Published: January 2019

A randomised, single-blind study to investigate patient-controlled epidural analgesia during labour was conducted using a solution of low-dose bupivacaine-fentanyl. Two groups (n = 25 in each) received a constant infusion supplemented by patient demand boluses, and midwife-administered boluses if required, the size of the infusion and patient increments varying between groups.

The quality of analgesia, as assessed by pain scores and patient ratings, was high and participant acceptability very high in both groups. Fourteen per cent of participants were withdrawn due to cephalad extension of block to T5 or supplementary bolus requirements outside the study protocol. Epidural side-effects were not troublesome and drug dose utilisation was low.

Significantly greater pain relief (P < 0.04) three hours after commencing patient-controlled epidural analgesia and a trend to fewer women requiring more than two supplementary midwife-administered boluses (P = 0.11) was seen in the group receiving a higher infusion rate. This group used significantly more bupivacaine (P < 0.04) and fentanyl (P < 0.001), but this did not appear to be clinically important with respect to degree of motor block or side-effects.

Patient-controlled epidural analgesia appears to be an effective and well accepted method of obstetric analgesia and warrants further investigation.
A Graded Combination Regimen for Maintenance of Gastric pH above 3.5 in Critically Ill Patients
Authors: Morris R. W. , Boyle M. , Jacobs S. , Torda T.
Published: January 2019

Prophylaxis of acute upper gastrointestinal bleeding by control of gastric pH has been widely advocated for intensive care patients. H2-blockers and antacids have been used and demonstrated to be incompletely effective at maintaining gastric pH above 4. A study of 100 patients measured the efficacy of two-hourly gastric pH measurement and titrated therapy consisting of five levels: 1. no therapy 2. ranitidine 50 mg 8 hourly intravenously 3. ranitidine plus Mylanta 30 ml 2 hourly by nasogastric tube 4. ranitidine plus Mylanta 60 ml 2 hourly and 5. ranitidine 100 mg 8 hourly intravenously plus Mylanta II 60 ml 2 hourly.

The level of treatment required by proportions of the total study group were (1) 15%, (2) 71%, (3) 96%, (4) 100%. Head-injured and intubated patients generally fell in the more resistant group while patients having had major elective surgery required lower levels of therapy.

If control of gastric pH is to be uniformly achieved, a technique of titrated therapy based on gastric pH measurements is supported as cheaper and more effective than other standardised treatment regimens.
Thickly and Thinly Applied Lignocaine-Prilocaine Cream Prior to Venepuncture in Children
Authors: Sims C.
Published: January 2019

EMLA cream (Astra Pharmaceuticals) which contains lignocaine and prilocaine, is widely used in a thick layer to reduce the pain associated with venepuncture. Application of smaller amounts of cream lowers cost and may reduce side-effects. The efficacy of a thick layer (using 2.0 ml) and a thin layer (using 0.5 ml) of lignocaine-prilocaine cream prior to venepuncture was compared in a randomised study of one hundred children. Pain with venepuncture was assessed using a behavioural rating scale as none, slight, moderate or severe. Children in the thin layer study group experienced slight pain more often than children in the thick layer study group (P < 0.01). No child in either group experienced moderate or severe pain. It is concluded that a thin layer of lignocaine-prilocaine cream is not as effective as a thick layer in producing the pain-free venepuncture which is desirable in children.
Acute Carbon Monoxide Exposure and Cerebral Blood Flow in Rabbits
Authors: Meyer-Witting M. , Helps S. , Gorman D. F.
Published: January 2019

Carbon monoxide (CO) 1% was administered to anaesthetised rabbits for 15 minutes. Despite a 28% ± 5.8 (SEM) fall in mean arterial blood pressure during the CO exposure, cerebral blood flow increased by 236% ± 36.5 in the left and 287% ± 28.9 in the right cortex. Cerebrovascular resistance was reduced by 70.6% ± 2.8 in the left and by 76.2% ± 3 in the right cortex. These changes were accompanied by an increase in intracranial pressure, a drop in body temperature and ventilation requirement, and a metabolic acidosis. When the CO was withdrawn all these parameters returned to normal over three hours. Hence, these vascular effects are reversible and consistent with the natural history of CO intoxication in humans. Carboxyhaemoglobin levels correlated well with hemispheric cerebral blood flow (r = 0.90; r = 0.98) and cerebrovascular resistance (r = 0.87; r = 0.97).
Quality of Blood Prepared for Autotransfusion in Primary Cemented Total Hip Replacement
Authors: Roberts D. R. D. , Mah E. T. , Nyman T. L. M. , Davis R. W.
Published: January 2019

We have measured levels of contaminants (products of cell lysis and other substances) in blood salvaged from patients undergoing primary cemented total hip replacement. Washing of this blood removed an average of 91.4% of the free haemoglobin mass, reduced white cell lysozyme concentrations by 86% and almost totally eliminated fats and particulate matter. Osmotic fragility was significantly improved by washing although not to control levels.
Use of the Cell Saver during Elective Abdominal Aortic Aneurysm Surgery — Influence on Transfusion with Bank Blood. A Retrospective Survey
Authors: Brown G. , Bookallil M. , Herkes R.
Published: January 2019

One hundred and two patients undergoing elective abdominal aortic aneurysm repair and admitted to ICU at RPAH in 1989/90 were studied.

In forty patients a cell saver was used during the operative procedure (Group CS) while in the remaining sixty-two patients intraoperative blood loss was drained and discarded conventionally (Group NCS). Preoperative ASA grade and postoperative APACHE score were similar in these two groups.

The amount of bank blood transfused intraoperatively was less in Group CS than in Group NCS (0.6 ±0.2 vs 3.3 ±0.3 units) (mean ± SEM) (P < 0.0001).

The total amount of bank blood transfused during hospital admission was also less in Group CS (1.5 ± 0.4 vs 4.8 ± 0.4 units, P < 0.0001). Of Group CS, 22 patients (55%) received no bank blood compared to two patients (3%) in Group NCS.

There was no difference between the groups with respect to postoperative haemoglobin and creatinine levels. ICU stay was similar in both groups.

We conclude that use of the cell saver reduces perioperative bank blood transfusion in elective abdominal aortic surgery.
Diaphragmatic Pacing: An Alternative to Long-Term Mechanical Ventilation
Authors: Tibballs J.
Published: January 2019

Electrical percutaneous stimulation of the phrenic nerves was first employed in 1948 by Sarnoff to provide temporary artificial ventilation in patients with respiratory failure.1 However, the technique was limited by development of infection around the electrode. Short-term radio frequency stimulation of the phrenic nerves was first utilised by Glenn in 19641 and adapted to long-term use in patients with central hypoventilation in 19683 and with traumatic quadriplegia in 1972.4 The technique employed alternate pacing of each hemi-diaphragm with high frequency stimulation (25–30 Hz) with a respiratory rate of 12 to 17 per minute which, in a series of 17 quadriplegic adults, although initially successful, was self-limiting because of eventual damage to the nerves and diaphragms. More recently, continuous bilateral simultaneous low frequency (up to 8 Hz) stimulation with a respiratory rate of 5 to 9 per minute has not induced myopathic changes.5 This phenomenon has been attributed to: 1. the conversion of the mixture of slow and fast twitch fibres in the diaphragm to a uniform population of fatigue resistant fibres induced by low frequency stimulation, and 2. the reduction in the total current necessary to achieve adequate gas exchange when both diaphragms contract simultaneously with the less frequent stimulation at lower energy. Diaphragmatic pacing has been applied to infants and children6–8 with emphasis on the selection of patients and optimum setting of stimulus parameters.9 This communication presents a case report of diaphragmatic pacing in a child with a review of the principles of application. The advantages and disadvantages compared to mechanical ventilation are also discussed.
Haemodynamic Effects and Uptake of Enflurane in Patients Undergoing Cardiac Surgery: Good versus Poor Myocardial Function
Authors: Myles P. S. , Storer R. , Millar C.
Published: January 2019

We measured haemodynamic effects and uptake of enflurane in patients undergoing cardiac surgery utilizing a standard anaesthetic technique of fentanyl 15 mcg/kg nitrous oxide 50%/enflurane 1%. We divided 22 patients preoperatively into two groups according to standard criteria: good and poor myocardial function. Regression lines could be drawn illustrating the relationship of cardiac output and uptake (at 1 minute: r = −0.56, P < 0.01; at 5 minutes: r = −0.43, P < 0.05; at 30 minutes: r = −0.31, P=0.08). Although patients with poor myocardial function had decreased uptake of enflurance (approximately 10–20%), this did not reach statistical significance. Fentanyl/nitrous oxide/enflurane anaesthesia provided stable haemodynamics, even in patients with poor myocardial function. Both groups had a shunt fraction of approximately 10% and an arterial: end-tidal carbon dioxide difference of approximately 3–4 mmHg.
A Blind Guided Technique for Placing Double-Lumen Endobronchial Tubes
Authors: Russell W. J.
Published: January 2019

A new technique is described to aid in achieving a correct blind insertion of an endobronchial tube. The tube is selected by length to fit the distance from the patient's mouth to carina. As the tube is inserted, the position of the endobronchial cuff is monitored. This is done by inflating the bronchial cuff in the trachea and after each breath, advancing the tube down the trachea until only one lung is inflated. This accurately identifies the bronchial cuff as just beyond the carina, at the entrance to the main bronchus. From here, the tube can be advanced precisely into the bronchus to give the optimal conditions for isolation of the right and left lungs.
Complications of Continuous Spinal Anaesthesia
Authors: Peyton P. J.
Published: January 2019

The practice of continuous spinal anaesthesia dates back to the beginning of the century. The history of the technique, and the problems which accompanied each method used, are reviewed. Complications encountered in current practice include post dural puncture headache; technical difficulties with insertion and removal of catheters; and a higher potential for nerve trauma, neurotoxicity, and method failure than seen with single-shot spinal anaesthesia. The question of the place of the technique in modern anaesthesia is addressed.
Prophylactic Intramuscular Ephedrine Prior to Caesarean Section
Authors: Rout C. C. , Rocke D. A. , Brijball R. , Koovarjee R. V.
Published: January 2019

Thirty healthy parturients, having given informed consent, were randomly allocated in a double-blind study to receive an intramuscular injection of either 0.9% sodium chloride (control), ephedrine 25 mg, or ephedrine 50 mg, 30 minutes prior to general anaesthesia for caesarean section. Nine patients (90%) in the 50 mg group and five patients (50%) in the 25 mg group demonstrated reactive hypertension of 20% or greater from control. The mean maximum increase in the 50 mg group was 28.2% (range 4.4–38.3%). Maternal pH was significantly lower (P = 0.03) in the ephedrine 50 mg group. Neonatal acid base status was significantly impaired in the ephedrine 50 mg group with umbilical venous pH (P = 0.0001) and umbilical arterial pH (P = 0.001) being significantly lower than the control group. The associated increase in umbilical arterial base deficit suggests a metabolic component due to fetal asphyxia related to decreased uterine blood flow. We conclude that the prophylactic administration of intramuscular ephedrine prior to spinal anaesthesia is associated with an unacceptably high incidence of maternal hypertension, and should the spinal fail and general anaesthesia be required, also results in adverse neonatal biochemical changes. The technique is therefore not to be recommended.
Oxygen Dissociation Curve in the Adult Respiratory Distress Syndrome
Authors: Huang W-N , Cade J. F. , Pain M. C. F.
Published: January 2019

The oxygen tension for half saturation (P50) was determined for venous blood in thirteen patients with the adult respiratory distress syndrome undergoing intensive therapy. The mean value for P50 was found to be significantly lower than the value found in ten normal control subjects (22.9 mmHg and 26.7 mmHg respectively; t = 3.03, P < 0.01).

The extent of reduction in P50 was not related to serum phosphate level nor was it a predictor of short-term outcome. It is unlikely that the slight left-shifted oxygen-haemoglobin dissociation curve contributes in a major way to an oxygen delivery deficiency and its cause is unexplained.
Derived Oxygen Saturations are not Clinically Useful for the Calculation of Oxygen Consumption
Authors: Myburgh J. A.
Published: January 2019

In critically ill patients, oxygen consumption (VO2) and delivery (Do2) are used to determine optimal haemodynamic management and to grade severity of illness. Vo2 may be measured by indirect calorimetry with metabolic gas monitoring systems or derived using the reverse Fick principle. Oxygen saturation (Sao2) may be measured directly by co-oximetry or derived by equations for incorporation into reverse Fick equations. A prospective study comparing Vo2 measured by these methods was performed in 20 critically ill patients. The mean Vo2 measured by the metabolic gas monitoring system (308 ± 63.9 ml/min) was significantly greater than that measured by reverse Fick using measured Sao2 (284 ± 72.0 ml/min) (P < 0.01). This difference may be due to intrapulmonary Vo2. When SaO2 was, calculated from three logarithmic equations and incorporated into the reverse Fick equations, calculated Vo2‘s were significantly greater (P < 0.001) than those measured by indirect calorimetry. Correlation was poor and wide limits of agreement (-118 to + 350 ml/min) were demonstrated. Vo2 should ideally be measured by indirect calorimetry in the critically ill, or if reverse Fick is used, SaO2 should be measured by co-oximetry as the use of equations for clinical measurement of SaO2 is clinically suspect.
Total Intravenous Anaesthesia versus Inhalational Anaesthesia for Dental Day Surgery
Authors: Lim B. L. , Low T. C.
Published: January 2019

Fifty young healthy and unpremedicated patients scheduled for removal of impacted teeth were randomly allocated to receive either total intravenous anaesthesia with propofol or conventional thiopentone/isoflurane/nitrous oxide anaesthesia. A double-blind postoperative assessment showed the former group to have a shorter reversal time and faster recovery of faculties, i. e. speech, memory as well as ability to sit up and walk without assistance (P < 0.01).

There was no incidence of hypotension and of awareness in either group. The incidence of headache, nausea and vomiting was higher in the thiopentone/isoflurane/nitrous oxide group.
Fault in a Selectatec Manifold Resulting in Awareness
Authors: Lum M. E. , Kee W. D. Ngan , Robinson B. J.
Published: January 2019

The Selectatec Vaporising System is a quick change system consisting of anaesthetic vaporisers of the Tec 3 and Tec 4 models and the compatibility manifold block on which these are seated on the anaesthetic machine backbar. There have been reports of difficulties with the seating and locking of the vaporisers which can cause a leak and failure of vapour delivery. The Faculty of Anaesthetists, Royal Australasian College of Surgeons (now Australian and New Zealand College of Anaesthetists) issued a hazard alert in March 1991 drawing attention to this potential fault.1 We present two cases of awareness associated with failure of internal seals within a Selectatec compatibility manifold block which did not have a detectable leak.
Analgesia after Caesarean Section with Intramuscular Ketorolac or Pethidine
Authors: Gin T. , Kan A. F. , Lam K. K. , O'Meara M. E.
Published: January 2019

We compared, in a double-blind randomised study, intramuscular ketorolac 30 mg (n = 49) and intramuscular pethidine 75 mg (n=5l) for analgesia after elective caesarean section under general anaesthesia.

Anaesthesia was induced with thiopentone and suxamethonium and maintained with atracurium, nitrous oxide and isoflurane. Intravenous fentanyl 100 μg was given after delivery of the neonate. In the recovery ward, patients who requested analgesia were allocated randomly to receive ketorolac 30 mg or pethidine 75 mg intramuscularly. Analgesia was assessed at intervals up to six hours, using a visual analogue scale and a four-point verbal scale, while duration of analgesia was taken as the time until the patient requested additional analgesia.

There was no difference in the duration of analgesia between groups (Mann-Whitney test P=0.27, Mantel-Haentszel test P=0.17). Twenty-six patients in the ketorolac group and 17 patients in the pethidine group requested further analgesia by 90 minutes. However, four patients in the ketorolac group and six patients in the pethidine group requested no further analgesia within 24 hours. Pain VAS and overall assessment of analgesia was similar between groups, although more side-effects (nausea, dizziness) were noted in the pethidine group.

Ketorolac 30 mg and pethidine 75 mg provided similar but variable quality of analgesia after caesarean section.
The Antinociceptive Effect of Epidural Lignocaine and Fentanyl during Lithotripsy
Authors: Fredman B. , Olsfanger D. , Blubstein H. , Jedeikin R.
Published: January 2019

To determine the antinociceptive effect of combining epidural fentanyl with lignocaine during non-immersion lithotripsy, 56 healthy patients were enrolled into a prospective, randomized, double-blind study. Epidural anaesthesia was induced with either lignocaine 300 mg alone, or lignocaine 300 mg, or 200 mg in combination with fentanyl 100 μg. Throughout the procedure analgesia was assessed by comparing the incidence of (a) spontaneous complaints of pain, (b) patients’ attempts to withdraw from the painful stimulus, (c) supplemental epidural lignocaine requirements, (d) the haemodynamic response to lithotripsy and (e) the time to first postoperative pain. The patients who received the fentanyl-lignocaine 300 mg combination required no supplemental lignocaine, experienced marginally less intraoperative pain and recorded lower mean arterial blood pressures when compared with lignocaine 300 mg alone. However, when the combination of lignocaine 200 mg and fentanyl 100 μg was administered, patients experienced significantly more pain, withdrew from the painful stimulus more often and received more supplemental lignocaine when compared with the other two treatment groups. No difference was found in the time to the first complaint of postoperative pain. Similarly, discharge times were unaffected by treatment modality.

We conclude that despite the addition of fentanyl, adequate analgesia during lithotripsy is dependent upon the dose of local anaesthetic administered.
A Simple Method for the Continuous Noninvasive Estimate of Cardiac Output Using the Maxima Breathing System. A Pilot Study
Authors: Miller D. M. , Wessels J. A.
Published: January 2019

The Maxima is a new breathing system which makes it possible to monitor cardiac output (Q) noninvasively and to follow trends continuously. When used as a rebreathing system in controlled ventilation, the Maxima selectively eliminates alveolar gas and no fresh gas (&Vdot;F) is eliminated. Without the need for a mixing chamber, eliminated CO2 (FĒCO2) may be measured directly. With steady state conditions, and assuming a respiratory quotient of 1, carbon dioxide production (&Vdot;CO2) = &Vdot;F x FĒCO2. The indirect Fick principle applied to. CO2 exchange (&Qdot; = &Vdot;CO2/venous-to-arterial CO2 content difference (CaCO2-CvCO2)) may be modified to &Qdot; = &Vdot;F x FĒCO2/(CaCO2-CvCO2). If &Vdot;F in the breathing system is adjusted so that FĒCO2 is equal to CaCO2-CvCO2, then &Qdot; = &Vdot;F. It was found that, in the presence of a normal haemoglobin (13.3 g.dl–1), & Qdot; = &Vdot;F when &Vdot;F was adjusted to achieve an FĒCO2 value of approximately 4.1%.

Cardiac output estimates were compared with those obtained using a thermodilution technique in five patients undergoing coronary artery bypass grafting and in four patients with septicaemia in the ICU. Cardiac outputs were estimated from 1. &Vdot;CO2 measurements and then 2. &Vdot;CO2 and haemoglobin (Hb). The result of 28 measurements on nine patients with methods 1. and 2. respectively yielded a correlation with thermodilution measurements: coefficient r = 0.91 and 0.94 with a bias of −10.5% and −0.05% and an accuracy of 14% and 9%.
Comparison of the Efficacy of Paracetamol versus Paracetamol, Codeine and Promethazine (Painstop®) for Premedication and Analgesia for Myringotomy in Children
Authors: Ragg P. , Davidson A.
Published: January 2019

This prospective double-blinded study compared the analgesic effectiveness and incidence of complications of a compound preparation Painstop® (Paedpharm Pty Ltd) containing paracetamol 12 mg, codeine 0.5 mg and promethazine 0.65 mg per 1.0 ml, dosage 1.0 ml/kg, with paracetamol 20 mg/kg. Ninety-five children aged 1 to 12 years, ASA 1-2, scheduled for myringotomy and drain tube insertion as a day procedure were randomized to receive Painstop or paracetamol 30 to 60 minutes prior to surgery. Preoperative drowsiness and complications on induction and postoperative sedation, pain and times to achieve goals were recorded.

The groups were comparable for age, gender, weight, anaesthetic technique and duration of surgery. Times to eye opening (P=0.05) and first oral intake (P=0.006) were significantly longer in the Painstop group. There was, however, no difference in times to discharge. Late sedation was more common in the Painstop group (P=0.03). Pain scores were low and similar in both groups and the need for additional analgesia was uncommon.
Barriers to Hepatitis C Transmission within Breathing Systems: Efficacy of a Pleated Hydrophobic Filter
Authors: Lloyd G. , Howells J. , Liddle C. , Klineberg P. L.
Published: January 2019

It has been suggested that breathing circuits contaminated with body fluids may provide a route of nosocomial patient-to-patient transmission of the hepatitis C virus. Thus, a number of authorities have recommended the use of breathing circuit filters to minimize such risks. The present study sought to simulate a humidified breathing circuit and evaluate two different designs of breathing circuit filters to determine their efficacy in preventing passage of the hepatitis C virus. A hydrophobic pleated-membrane filter consistently prevented the passage of hepatitis C virus while a large-pore “electret” filter design was ineffective. We conclude that not all filter types are equally suited to preventing the passage of viruses and we therefore consider it essential that, if filters are intended to prevent the passage of named pathogens in a humidified breathing circuit, they should be evaluated in a similar experimental system to that described in order to prove their efficacy.
Adverse Cardiovascular Effects of Ketamine Infusion in Patients with Catecholamine-Dependent Heart Failure
Authors: Christ G. , Mundigler G. , Merhaut C. , Zehetgruber M. , Kratochwill C. , Heinz G. , Siostrzonek P.
Published: January 2019

The longterm effects of ketamine on haemodynamic parameters and exogenous catecholamine requirements were studied in twenty-five critically ill patients with catecholamine-dependent heart failure. Following sedation with midazolam (0.15±0.07 mg.kg–1.h–1) and sufentanil (0.88±0.33 μg.kg–1.h–1), patients with impaired left ventricular function (left ventricular ejection fraction area 30±7%) were randomly assigned to receive ketamine (2.5±0.9 mg.kg–1.h–1) and midazolam (Group A) or remained on sufentanil/midazolam (Group B). Haemodynamic measurements were performed throughout the first 24 hours after randomization. In group A cardiac index decreased by 21% (P=0.01), mean arterial pressure increased by 13% (P=0.01), mean pulmonary artery pressure by 14% (P=0.04), pulmonary capillary wedge pressure by 20% (P=0.03), and systemic vascular resistance index by 38% (P<0.001). No significant cardiovascular effects were observed in Group B. Neither group had significant changes of exogenous catecholamine requirement.

In conclusion, ketamine exhibits potential negative cardiovascular effects in patients with catecholamine-dependent heart failure. Therefore, ketamine should not be considered a first line drug for longterm sedation of patients with impaired left ventricular function.