bluuebunny/crossref_metadata_2025 huggingface dataset:
A Modified Fascia Iliaca Compartment Block Has Significant Morphine-Sparing Effect after Total Hip Arthroplasty
Authors: Stevens M. , Harrison G. , Mcgrail M.
Published: January 2019

We assessed whether a modified fascia iliaca compartment block in unilateral total hip arthroplasty provides a morphine-sparing effect in the first 24 hours. This involved a randomised, double blind study of 44 patients. Both groups received a modified fascia iliaca block with the trial group receiving 30 ml 0.5% bupivacaine with 1:200,000 adrenaline, 150 μg clonidine and 9 ml 0.9%> saline and the control group receiving 40 ml 0.9% saline. Otherwise both groups received identical care with a subarachnoid block for operative anaesthesia. Patient-controlled morphine analgesia was commenced postoperatively and data were collected at three, six, 12 and 24 hours post commencement of surgery. We found that the trial group used less morphine at 12 and 24 hours (P <0.001). The median morphine usage at 24 hours was 37.5 mg in the control patients and 22 mg in the trial patients. Pain scores were similar between groups. We conclude that a modified fascia iliaca compartment block has a significant morphine-sparing effect in unilateral total hip arthroplasty.
The Influence of Head Rotation on Proseal™ Laryngeal Mask Airway Sealing during Paediatric Myringotomy
Authors: Choi W. J. , Kim Y. H.
Published: January 2019

Myringotomy with ventilation tube insertion in children involves turning the head from neutral to allow surgical access to the ear. In adults, rotation of the head from the midline generally increases the oropharyngeal leak pressure when a ProSeal™ laryngeal mask airway (PLMA) is used to manage the airway. There are concerns that these manoeuvres may distort or obstruct the paediatric airway. Paediatric sizes (1.5, 2.0 and 2.5) of the PLMA differ from the adult versions in that they do not have a dorsal cuff. This study examines the effect of these head position changes on the seal of the PLMA in children. Twenty-nine children (ASA 1-2, aged 0.9 to 7.5 years) scheduled for myringotomy were recruited. After PLMA insertion, oropharyngeal leak pressure and fibreoptic determined PLMA position scores were measured in the neutral position and with head rotation of 45° to the left or right. Fibreoptic positioning scores were similar in all positions. Head rotation was associated with a statistically significant but modest increase in oropharyngeal leak pressure versus the neutral position (P <0.05). After rotating the head from neutral, 38% (11 of 29) of subjects had an increase of oropharyngeal leak pressure of at least 2 cmH2O. Only 7%> (2 of 29) of subjects had a decrease in oropharyngeal leak pressure with head rotation, the maximum decrease being 2 cmH2O. Airway obstruction did not occur in any of the positions. We conclude that the efficacy of the seal for the pediatric sizes PLMA is improved by head rotation for myringotomy.
Critically Ill Children in Non-Paediatric Intensive Care Units: A Survey, Review and Proposal for Practice
Authors: Austin J. D.
Published: January 2019

Despite strong arguments in favour of centralising care of critically ill children to paediatric intensive care units, around 2000 children per year are cared for in non-paediatric intensive care units in Australia and New Zealand. This paper reports a survey of consultants from 13 such units that admitted over 50 children in 2002 and 2003, to find out what factors affect the decision to keep critically ill children locally or transfer them to a paediatric intensive care unit and what infrastructure existed to support local care of these children. The results of this survey form the basis for a proposal to improve care of critically ill children in the non-paediatric intensive care units. The four key elements of this proposal are: the use of protocols, routine consultation with the regional paediatric intensive care unit, the use of telemedicine, and enhancing skills and experience of local staff. Evidence supporting these measures as well as the evidence for centralising care of critically ill children is reviewed.
Missed Foreign Body and Necessitans Empyema
Authors: Boots R. J. , Windsor M. N.
Published: January 2019

A recurrent empyema over a three-month period ultimately presented as an empyema necessitans (an empyema pointing through the skin) due to Fusobacterium varium. The recurrence of the empyema was due to an animal vertebra aspirated, during a bar-room altercation, into the right main bronchus, mimicking an endobronchial tumour.
The Management of a Super Morbidly Obese Parturient Delivering Twins by Caesarean section
Authors: McDonnell N. J. , Paech M. J.
Published: January 2019

A super morbidly obese (230 kg, body mass index 76 kg/m2) patient presented to our service for a planned elective caesarean section for twin delivery. She subsequently underwent a non-elective caesarean section after normal working hours under combined spinal epidural anaesthesia with invasive monitoring. Complex cases such as this, especially in the obstetric setting, require thorough multidisciplinary planning, communication and expertise but can be safely and successfully performed in dedicated stand-alone centres.
Geoffrey Kaye—a man of many parts
Authors: Westhorpe R. N.
Published: January 2019

Geoffrey Kaye was primarily an anaesthetist, but there were many facets to his life, not all of them involving medicine. He was also a researcher, author, teacher, engineer, inventor, metalworker, organiser, traveller, visionary and collector.

Geoffrey Kaye had a vision for Australian anaesthesia. He put many of his own resources into the establishment of a ‘centre of excellence’ where the needs of a specialist society could be accompanied by an active educational and research facility. He was so far ahead of his time that his vision foundered on lack of enthusiasm from others.

There is no doubt that Geoffrey is best remembered for his lasting legacy, the Geoffrey Kaye Museum of Anaesthetic History, now housed at the Australian and New Zealand College of Anaesthetists in Melbourne. It is his core collection of equipment, documents and memorabilia that now gives us insight into the development of our specialty.

His collecting extended beyond his love of medicine. He was renowned for his collection and knowledge of exquisite tableware, porcelain, and furniture, much of which now remains in the Ian Potter Museum collection, also in Melbourne.
Decline and Fall—a Tragedy in Three Acts
Authors: Holland R.
Published: January 2019

Pre World War II, practising anaesthetists in Australia relied heavily on two companies—Commonwealth Industrial Gases and H.I. Clements & Son—for technical support. Post-war, these two were joined by Telectronics, the Australian company which exploited the electronic revolution in monitoring. From a position of profitability and major market share, all three fell to earth for commercial, political and managerial reasons.
The Manhattan Legacy
Authors: Holmes C. McK.
Published: January 2019

The Manhattan Project was the highly secret American atomic research study which led to the making of the atom bomb. What is not so well known is that before the Project, fluorine was a difficult and dangerous element, while afterwards it became a key ingredient in all the new inhalational anaesthetics. Prior to this, the only practical inhalational agents available apart from nitrous oxide, ethylene and cyclopropane, (and a few others of short-lived popularity like acetylene) were non-halogenated ethers and some chlorinated compounds such as chloroform and ethyl chloride.

When chemists learnt how to handle fluorine, a whole new world opened up, first with the ‘Freons’ as used in refrigeration and then the halogenated anaesthetics. Along the way, many halogenated compounds other than ethers were tried but abandoned, and now we are left effectively with two halogenated ethers. Is this the end of the line for inhalational anaesthesia?
Unravelling the Mystery of Malignant Hyperthermia
Authors: Ball C.
Published: January 2019

Malignant hyperthermia was an unknown condition in 1960 although there had always been occasional patients who died mysteriously under anaesthesia. The nature of the disease became apparent when a young Melbourne man presented that year with a compound fracture and a family history of deaths under anaesthesia. He survived his anaesthetic due to the combined efforts of the anaesthetist and the surgeon. His family history was then investigated by the physicians. Over the next 20 years the cause of the disease was discovered and eventually a treatment was found. This article is based around a series of interviews with many of the participants in this story.
Chlorhexidine - Pharmacology and Clinical Applications
Authors: Lim K. -S. , Kam P.C.A.
Published: January 2019

chlorhexidine is a widely used skin antisepsis preparation and is an ingredient in toothpaste and mouthwash. It is an especially effective antiseptic when combined with alcohol. Its antimicrobial effects persist because it is binds strongly to proteins in the skin and mucosa, making it an effective antiseptic ingredient for handwashing, skin preparation for surgery and the placement of intravascular access. Catheters impregnated with chlorhexidine and antimicrobial agents can reduce the incidence of catheter-related bloodstream infections. Contact dermatitis related to chlorhexidine is not common in health care workers. The incidence of contact dermatitis to chlorhexidine in atopic patients is approximately 2.5 to 5.4%. Acute hypersensitivity reactions to chlorhexidine are often not recognised and therefore may be underreported. This review discusses the pharmacology, microbiology, clinical applications and adverse effects of chlorhexidine.
The Effect of Timing of Application of Positive End-expiratory Pressure on Oxygenation during One-lung Ventilation
Authors: Ren Y. , Peng Z. L. , Xue Q. S. , Yu B. W.
Published: January 2019

Many studies have confirmed that applying positive end-expiratory pressure (PEEP) to the dependent lung during one-lung ventilation (OLV) improves oxygenation. Our purpose was to investigate the best time and level of PEEP application. Thirty patients undergoing thoracic surgery were randomised into three groups. After 20 minutes of two-lung ventilation (TL V) in the lateral position, all patients received OL V for one hour. During OLV, 0, 5, 10 cmH2O PEEP were applied in order in group A, with each level sustained for 20 minutes. Group B had 5 cmH2O PEEP applied and maintained for one hour. Patients in group C received PEEP with levels set in the opposite order to that of group A. The ventilation model was then converted to TLV.PaO2, PaCO2 and respiratory mechanical variables were compared at five different time points among groups, 20 minutes after TLV (T1), 20 (T2), 40 (T3) and 60 minutes (T4) after OLV, and 20 minutes after conversion to TL V (T5). We found that PaO2 was lower in group A than the other two groups at T2 (P <0.05). PaO2 decreased significantly at T5 compared with T1 (P <0.05) in group A only. When PEEP was set to 10 cmH2O, the airway pressure increased significantly (P <0.05). These findings indicate that PEEP applied at the initial time of OLV improves oxygenation most beneficially. Five cmH2O PEEP may produce this beneficial effect without the increase in airway pressure associated with 10 cmH2O PEEP.
Acute Airway Obstruction Secondary to Achalasia Mega-oesophagus
Authors: Ho V. , Whiting P.
Published: January 2019

Acute airway obstruction is a very rare presentation of achalasia. We report the case of a 78-year-old woman with previously undiagnosed achalasia who presented with acute respiratory distress and stridor due to tracheal compression by mega-oesophagus. Anaesthetists and physicians caring for patients with achalasia must be aware of the need for emergency oesophageal decompression in this rare and life-threatening condition.
Continuous Infusion of Subcutaneous Compared to Intravenous Insulin for Tight Glycaemic Control in Medical Intensive Care Unit Patients
Authors: Bodur H. A. , Saygili F. , Saygili S. , Doganay L. H. , Yesil S.
Published: January 2019

The aim of this randomised controlled study was to compare continuous subcutaneous insulin infusion using an insulin pump with the traditional continuous intravenous infusion method for tight glycaemic control. Sixty patients admitted to our University Hospital medical intensive care unit with an initial blood glucose level over 6.1 mmol/l, were enrolled and randomised into two treatment groups: the subcutaneous insulin group received continuous subcutaneous insulin infusion and the intravenous group received insulin by traditional intravenous infusion with infusers. Three patients died in the first 24 hours and were excluded from the final analysis. Insulin therapy was administered to both groups according to the previously designed and used protocol in the department. The target glucose level was 4.4 to 6.1 mmol/l. There was no significant difference in mortality between the groups. However mean blood glucose level was found to be lower (6.56±0.82 mmol/l vs. 7.85±1.6 mmol/l, P=0.00055) in the subcutaneous insulin group. According to Vogelzang's hyperglycaemic index, better glycaemic control was achieved in the subcutaneous insulin group while there was no significant difference in terms of hypoglycaemic events. Daily insulin bolus and infusion requirements were also significantly lower in the subcutaneous insulin group. Despite the small number of patients involved in this study in a medical intensive care unit, strict blood glucose control using a subcutaneous insulin pump was achieved more efficiently than the traditional intravenous infusion method without increasing hypoglycaemic events.
The use of Extra Corporeal Carbon Dioxide Removal in the Management of Life-Threatening Bronchospasm Due to Influenza Infection
Authors: Twigg S. , Gibbon G. J. , Perris T.
Published: January 2019

We report the use of the Novalung® interventional Lung Assist Extra corporeal carbon dioxide removal (Novalung GmbH, Lotzenacker3, D-72379 Hechingen, Germany) to treat a 46-year-old female with life threatening bronchospasm secondary to influenza infection. Despite maximal treatment she develope hypercapnia and acidosis. The necessity for high inflation pressures led to the development of gross emphysema. Use of the interventional Lung Assist enabled a rapid correction of hypercapnoea and allowing a reduction in airway pressures, reducing further barotrauma. Subsequent resolution inflammatory process allowed removal of the interventional Lung Assist after 11 days. She was successfully from mechanical ventilation and made a full recovery.
Against the Odds
Authors: Holland R.
Published: January 2019

The history of the development of humidifiers as a necessaryaccompaniment to mechanical ventilation is a fascinating one. In New Zealand in the 1960s, Fisher and Paykel, an established importer of a variety of household appliances, launched into the design and manufacture of humidifiers following the requirements envisaged at that time, for optimal use in the intensive care setting. This was a completely new venture for the company and led to the establishment of a separate Fisher and Paykel Health Care company for medical equipment manufacture, which has continued successfully to the present day.
History of Analgesia and Regional Anaesthesia through Philately
Authors: Rangappa P.
Published: January 2019

Medical philately is the study of postage stamps commemorating events and pioneers in the field of medicine. In 1929, Dr Fielding H. Garrison, doyen of medical history, remarked that stamps were a great resource for the medical fraternity, something he hoped that physicians would soon recognise. His prediction has hardly come to fruition in the years since then, with medical philatelic articles rarely seen in the medical press.

The history of pain medicine is unique, diverse and extremely interesting, with many chemists, physicists, philosophers, contributing in their own way over centuries to pave the path to present day pain medicine.
From Collection to Museum: The Development of the Geoffrey Kaye Museum of Anaesthetic History
Authors: Triarico E.
Published: January 2019

Located at the Australian and New Zealand College of Anaesthetists (ANZCA) headquarters in Melbourne, Victoria, this internationally significant collection was founded in 1935 by renowned Australian anaesthetist Dr Geoffrey Kaye (1903 to 1986). Although it has always been referred to as a museum, it lacked the necessary management structure and infrastructure to meet museum standards.

In March 2003, the first full-time professionally trained Museum Curator, Ms Elizabeth Triarico, was employed by ANZCA to work with the Honorary Curator, Dr Rod Westhorpe, and the Honorary Assistant Curator, Dr Christine Ball, to build on past achievements and to develop the collection into an accessible and relevant modern museum. Ms Triarico has extensive museum management experience with emphasis on management of major projects, collection management, strategic planning, marketing, interpretation and exhibition development.

This paper outlines the management issues and innovative strategies involved in developing this important collection into a professionally managed museum based on best practice standards. It illustrates the benefits of introducing a clear vision and an agreed longterm management plan based on Museums Australia (Victoria) Museum Accreditation Program guidelines.
A National Survey on the Practice and Outcomes of Mechanical Ventilation in Korean Intensive Care Units
Authors: Koh Y. , Lim C. M. , Koh S. O. , Ahn J.-J. , Kim Y. S. , Jung B. H. , Cho J. H. , Lee J. H. , Lee M. G. , Jung K. S. , Kwon O. J. , Lee Y. J.
Published: January 2019

A study was undertaken to describe the practice and outcomes of mechanical ventilation throughout Korea. This prospective cohort study was conducted over a three-month period enrolling patients (n=519) who received mechanical ventilation for more than 72 hours in 21 university hospital intensive care units throughout Korea.

The most common indication for mechanical ventilation was acute respiratory failure. The most common cause of acute-on-chronic respiratory failure was tuberculous lung disease. The most common initial mode for ventilation was volume-controlled ventilation. The mean tidal volume of acute respiratory distress syndrome patients was 7.6 ml/kg of the predicted body weight and the mean positive end-expiratory pressure was 9.4 cmH2O. The weaning success rate at 28 days was 50.3%. Pressure support and the T-piece were most commonly used as initial and final weaning modes respectively. Preventive measures against deep vein thrombosis during mechanical ventilation were performed more frequently in intensive care units with full-time critical care physicians than those without such physicians. Multivariate analysis showed that the APACHE II score, indication for mechanical ventilation, respiratory rate at 72 hours, enteral feeding and prophylaxis of deep vein thrombosis were prognostic factors for survival.

In Korean intensive care units, tuberculous lung disease remains an important cause for mechanical ventilation. The practice of mechanical ventilation in Korean intensive care units in general appeared to comply with the current international recommendations with regard to lung protection and weaning. However, intensive care units lacking critical care physicians seemed to be adopting fewer ancillary measures, such as deep vein thrombosis prophylaxis.
Some Scientific Reflections on Possible Mechanisms of General Anaesthesia
Authors: Carmody J. J.
Published: January 2019

The challenge to achieve a gestalt understanding of general anaesthesia is really dependent upon an understanding of the elusive concept of consciousness. Until very recently, anaesthesia has been understood to depend fundamentally on the lipid solubility of anaesthetic agents, unsurprisingly a misleading view which has followed from the greater simplicity of lipid chemistry compared with protein chemistry and, it is contended here, from a serious misunderstanding of the older experimental data. Nonetheless, because an over-simplistic view of lipids pertains in much pharmacological thinking about anaesthesia, this paper devotes some attention to potentially relevant aspects of lipid function and also to concepts of anaesthesia which are based on the properties of intracellular and extracellular water. It is argued that the more correct pharmacological explanation is likely to be action at hydrophobic sites of crucial functional molecules, most plausibly protein molecules: empirical data which support such actions are presented and considered.

Anaesthetic actions on a range of such proteins are discussed, with the emphasis on general neurophysiological principles, with the intent of avoiding the mire into which detailed consideration of actions at specific sites of putative function in the central nervous system can lead. Those experimentally-documented actions include influences on the proteins which constitute the Na+-ion conductance channels in axonal membranes (which are the basis for action potentials); on the Ca2+-ion channels which are crucial for neurotransmitter secretion from nerve terminals; on the properties of the ion channels in the post-synaptic membranes of the neurons which are the targets for transmitter action; on components of the “second messenger” systems of target neurons; as well as actions on metabolically significant enzymes (notably cytochrome P450).

The overall argument is that the concept of anaesthetic actions on lipids should be abandoned in favour of one which is consistent with the general pharmacological principle of drug action at specific receptor sites, i.e. a targeted action at unique loci on relevant proteins.
Labour Management of a Woman with Carnitine Palmitoyl Transferase Type 2 Deficiency
Authors: Slater P. M. , Grivell R. , Cyna A. M.
Published: January 2019

Carnitine palmitoyl transferase (CPT) type 2 deficiency is a disorder of mitochondrial fatty acid oxidation. In situations where energy stores are inadequate, such as may occur during labour, women with CPT type 2 deficiency are at risk of rhabdomyolysis. There is limited experience in the management of women with this condition in labour. We report a case of successful labour management of a woman with CPT type 2 deficiency, together with a brief review of the published case reports and a discussion of the issues surrounding anaesthetic management.
Prevalence of Vitamin Deficiencies on Admission: Relationship to Hospital Mortality in Critically Ill Patients
Authors: Corcoran T. B. , O'Neill M. A. , Webb S. A. R. , Ho K. M.
Published: January 2019

Vitamin deficiency is believed to be common in critical illness. Water soluble and antioxidant vitamins are those most frequently used for supplementation in these patients. There are no data to confirm the prevalence of vitamin deficiencies in high-risk emergently admitted intensive care patients, nor their association with hospital mortality.

One hundred and twenty-nine consecutive, critically ill patients who were emergently admitted to intensive care were enrolled in this prospective observational cohort study. Patient data including diagnosis, source of admission and severity of illness scores 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. Multivariate stepwise logistic regression modelling was performed to examine the association of vitamin concentrations with hospital mortality. Fifty-five patients (43%) had a biochemical deficiency of one of the five vitamins on admission to the intensive care unit. A total of 18 patients died (14%) during their hospital stay (15 of those in the intensive care unit). Moderate correlations with C-reactive protein concentrations were demonstrated for Vitamins B12, A and E (Spearman's r=0.309, −0.541 and −0.299, P=0.001, 0.001 and 0.007 respectively). Hospital mortality was significantly associated with age, APACHE II score, admission and maximum Sequential Organ Failure Assessment scores and admission source in the univariate analyses. Multivariate analysis did not demonstrate an association between biochemical deficiency and mortality. Biochemical deficiencies of water-soluble and antioxidant vitamins are common on admission in unplanned or emergency admissions to the intensive care unit, but we could not demonstrate an independent association with hospital mortality.
An Update on C-reactive Protein for Intensivists
Authors: Ho K. M. , Lipman J.
Published: January 2019

This review aims to summarise the physiology of C-reactive protein (CRP), its possible roles and limitations as an inflammatory and infective marker in intensive care medicine, and also the emerging roles of CRP in the pathogenesis of cardiovascular and autoimmune diseases. Observational and animal studies on uses of CRP were retrieved from the PubMed database without any language restrictions. Quantitative data were not pooled because of the heterogeneity of patient characteristics and disparate ways in which CRP was studied. Serum CRP concentrations are determined by the synthetic rate of its production in the liver regulated predominantly by interleukin-6. It has a half-life of 19 hours and is relatively slow in its onset and offset in response to an acute inflammatory process when compared to procalcitonin. It has some favourable properties and limitations as an inflammatory marker. An elevated CRP concentration is not specific to infections and the absolute CRP concentrations cannot be used to differentiate between bacterial, fungal and severe viral infections. The dynamic response of CRP to therapy that aims to modify the underlying inflammatory process and the clinical context of a patient are of pivotal importance when CRP concentrations are interpreted. CRP is found to be a significant partaker and prognostic factor in a wide range of cardiovascular and chronic diseases. In summary, CRP concentration is an important prognostic factor of many acute and chronic diseases. Serial CRP measurements may be useful to reflect a patient's response to therapy that aims to modify the underlying inflammatory process.
Relative Efficiency of Two Warming Devices during Laparoscopic Cholecystectomy
Authors: Kadam V. Rao , Moyes D. , Moran J. L.
Published: January 2019

Intraoperative hypothermia is a known consequence of general anaesthesia. Forced air warming devices are commonly used to prevent hypothermia in anaesthesia, but there are limited data on the use of radiant warming devices. Previous trials comparing the efficacy of forced air and radiant warming devices have reported discordant results. The current study evaluated the efficacy of these devices during elective laparoscopic cholecystectomy, where surgery was expected to last >60 minutes. Twenty-nine patients were randomised to either a forced air warming device (Warm-touch™; group 1, n=15) or a radiant warming device applied to the face (Sun-touch™; group 2, n=14). All fluids were given via a standardised fluid warmer set at 41°C. Oesophageal temperature was measured every 15 minutes until the end of the procedure. Between-group, over-time temperatures and interaction were analysed using a linear mixed model. Statistical significance was ascribed at P ≤0.05. The median (range) time of surgery was 90 (60 to 180) minutes. Mean (SD) oesophageal temperatures in the Warm-touch and Sun-touch groups were at 15 minutes 36.2 (0.30)°C and 36.2 (0.57)°C, and at 90 minutes 36.2 (0.44)°C and 35.9 (0.29)°C respectively. There was no statistically significant temperature difference between groups (P=0.69) or over time (P=0.61), and no interaction between time and treatment group (P=0.97). Postoperative headache was recorded in four Sun-touch and no Warm-touch patients (P=0.04). No difference in the efficacy of the Sun-touch warming device compared with the Warm-touch was demonstrated. Operational-mode side-effects may limit the use of the Sun-touch device.
Withdrawal of Intensive Care Treatment at Home – ‘a Good Death’
Authors: Kumar G. , Obuch S. , Vyakarnam P.
Published: January 2019

A patient with end-stage congestive cardiac failure and acute renal failure was admitted to the intensive care unit for inotropic support. Following no improvement with treatment, the focus of care shifted to the patient's comfort, palliative care and family support. She wished to die at home and therefore all efforts were made to fulfil her desire. This was achieved and she was discharged from the intensive care unit on inotropes and allowed to die in the comfort of her own home, with the withdrawal of treatment occurring only when the patient was ready.
A ‘Shock Room’ for Early Management of the Acutely Ill
Authors: Piagnerelli M. , Van Nuffelen M. , Maetens Y. , Lheureux P. , Vincent J.-L.
Published: January 2019

Our 850-bed, academic, tertiary care hospital uses a four-bed dedicated ‘shock room situated between the Departments of Emergency Medicine and Intensive Care to stabilise all acutely ill patients from outside or inside the hospital before transfer to the intensive care unit or other department. Admitted patients stay a maximum of four hours in the shock room. In this article we describe our experiences using this shock room by detailing the demographic data, including time and source of admission, diagnosis and outcome, for the 2514 patients admitted to the shock room in 2006. The most common reasons for admission were cardiac (33%) and neurological (21%) diagnoses. After diagnosis and initial treatment, 54% of patients were transferred to an intensive care unit or a coronary care unit; 2.5% of patients died in the shock room. The shock room provides a useful area of collaboration between emergency department and intensive care unit staff and enables acutely ill patients to be assessed and treated rapidly to optimise outcomes.
Anaesthesia and Right Ventricular Failure
Authors: Forrest P.
Published: January 2019

Acute right ventricular (RV) failure has until recently received relatively little attention in the cardiology, critical care or anaesthesia literature. However, it is frequently encountered in cardiac surgical cases and is a significant cause of mortality in patients with severe pulmonary hypertension who undergo non-cardiac surgery.

RV dysfunction may be primarily due to impaired RV contractility, or volume or pressure overload. In these patients, an increased pulmonary vascular resistance (PVR) or a decreased aortic root pressure may lead to RV ischaemia, resulting in a rapid, downward haemodynamic spiral. The key aspects of ‘RV protection’ in patients who are at risk of perioperative decompensation are prevention, detection and treatment aimed at reversing the underlying pathophysiology. Minimising PVR and maintaining systemic blood pressure are of central importance in the prevention of RV decompensation, which is characterised by a rising central venous pressure and a falling cardiac output.

Although there are no outcome data to support any therapeutic strategy for RV failure when PVR is elevated, the combination of inhaled iloprost or intravenous milrinone with oral sildenafil produces a synergistic reduction in PVR, while sparing systemic vascular resistance. Levosimendan is a promising new inotrope for the treatment of RV failure, although its role in comparison to older agents such as dobutamine, adrenaline and milrinone has yet to be determined. This is also the case for the use of vasopressin as an alternative pressor to noradrenaline. If all else has failed, mechanical support of the RV should be considered in selected cases.
Perforation of and Intubation through the Palatoglossal Fold
Authors: Bartlett D. S. , Grace R. , Newell S.
Published: January 2019

Perforation of pharyngeal soft tissues on intubation is rare. We present a case where the endotracheal tube punctured the palatoglossal fold before passing into the trachea. The patient was ventilated for eight days in intensive care before identification of the complication. It is difficult to estimate the frequency of pharyngeal perforation as it rarely occurs. There is however, an increased incidence in difficult intubations, emergency airway management, inexperienced operators and technique used.
Communication Failure in the Intensive Care Unit – Learning from a near Miss
Authors: Hendel S. A. , Flanagan B. T.
Published: January 2019

A 51-year-old female patient with Guillain-Batré syndrome was given three times the intended dose of intravenous human immunoglobulin while admitted to a tertiary intensive care unit. The error went unnoticed for seven hours and appears to have been the result of several successive breakdowns in communication between key staff. The patient, fortunately, made a full recovery.

This report analyses the communication failure and explores possible ways of avoiding similar occurrences in the future.
The Influence of Gender and Experience on Intubation Ability and Technique: A Manikin Study
Authors: Waddington M. S. , Paech M. J. , Kurowski I. H. S. , Reed C. J. , Nicholls G. J. , Guy D. T. , Day R. E.
Published: January 2019

Female anaesthetists in early training commonly question whether their strength is adequate for tracheal intubation. This study investigated the influence of gender and experience on intubation ability and laryngoscopic technique.

A manikin model and purpose-designed force-transducing laryngoscope was used to test three cohorts at different levels of experience (novice, intermediate and experienced males and females, n = 65) for the axial force and torque exerted, best laiyngoscopic view obtained, success with and time for intubation and laryngoscopic technique.

There were no significant differences between novice or experienced female and male intubators in markers of their ability to intubate or in the forces generated. For novice females compared with novice males, mean success rate was 90% (80.2 to 99.9) versus 97% (91.1 to 100, P=0.29); and mean time to intubate 24 seconds (19 to 29 seconds) versus 18 seconds (14 to 21 seconds, P=0.057). With experience, the forces generated during intubation reduced and ability improved. Proximal laiyngoscope grips (close to the blade) generated lower forces than distal grips.

Female and male intubators did not differ in ability to intubate or in the forces they exerted during direct laiyngoscopy.
Arytenoid Subluxation after a Difficult Intubation Treated Successfully with Voice Therapy
Authors: Tan V. , Seevanayagam S.
Published: January 2019

Arytenoid subluxation is a rare laryngeal injury that may follow instrumentation of the airway and present as hoarseness, vocal fatigue, stridor, dysphagia, odynophagia and sore throat. We report the case of an 88-year-old man with type 2 diabetes mellitus who developed this complication during a difficult intubation where a Macintosh laryngoscope and gum elastic bougie were used to facilitate intubation. Previously considered to play a minor role in treatment, voice therapy was used successfully in this patient to correct subluxation of the arytenoid, with prompt resolution of his symptoms.
Diagnosis of Postoperative Arrhythmias following Paediatric Cardiac Surgery
Authors: Skippen P. W. , Sanatani S. , Gow R. M. , Froese N.
Published: January 2019

Arrhythmias are commonly encountered in the paediatric intensive care unit setting, most frequently in the setting of postoperative congenital heart disease. Postoperative arrhythmias are an important cause of morbidity in children in the postoperative period following cardiac surgery for congenital cardiac lesions. It is important for all paediatric critical care physicians involved in the care of these children to understand the potential mechanisms involved and how to make an accurate diagnosis. The existing literature has focused on small groups and specific arrhythmias. There is a paucity of literature to guide the clinician in approaching arrhythmias in the paediatric intensive care unit setting. Our objective was to review the recognition and diagnosis of paediatric arrhythmias in the postoperative period following congenital cardiac surgery. Timely and accurate identification of the rhythm disturbance is mandatory and allows for the institution of effective, rhythm specific management strategies.
Hypercapnia Test and Weaning outcome from Mechanical Ventilation in COPD Patients
Authors: Raurich J. M. , Rialp G. , Ibáñez J. , Ayestarán I. , Llompart-Pou J. A. , Togores B.
Published: January 2019

We evaluated the hypercapnia response test as a weaning outcome predictor from mechanical ventilation in patients with chronic obstructive pulmonary disease (COPD).

We studied 44 COPD intubated patients considered ready for a weaning trial. The hypercapnia test was based on the modified method of re-inhalation of expired air. Through the hypercapnic test we calculated the ratio of the change in minute volume (VE) to the change in PaCO2 (ΔVE/ΔPaCO2), the change in airway occlusion pressure at 0.1 second of inspiration (P0.1) to change in PaCO2 (ΔP0.1/ΔPaCO2), the ratio of the change in P0.1 to baseline PaCO2 (ΔP0.1/PaCO2) and the ratio of the change in VE to baseline PaCO2 (ΔVE/PaCO2).

Nineteen patients were successfully weaned and 25 patients failed. No differences in baseline clinical characteristics were found between the two groups. Weaning failure COPD patients had lower ΔP0.1/ΔPaCO2 (0.19±0.11 and 0.34±0.20 cm H2O/mmHg respectively, P=0.006) and lower ΔVE/ΔPaCO2 (0.21±0.15 and 0.40±0.22 l/min/mmHg respectively, P=0.002) than successfully weaned patients. The area under the receiver operating characteristic curve to discriminate weaning outcome was for the baseline PaCO2 0.81 (95% confidence interval: 0.66 to 0.91), hypercapnic PaCO2 0.76 (0.61 to 0.88), hypercapnic drive response 0.74 (0.59 to 0.86), hypercapnic ventilatory response 0.76 (0.60 to 0.87), ΔP0.1/PaCO2 0.76 (0.60 to 0.87) and for the ΔVE/PaCO2 0.81 (0.67 to 0.91).

COPD patients with weaning failure have a significantly more blunted response to the hypercapnia response test than weaning success patients. This test could be useful to predict weaning failure patients if the combined values of the hypercapnic drive and hypercapnic ventilatory response were below the threshold values.
Incidence and Risk Factors for Chronic Pain after Caesarean Section under Spinal Anaesthesia
Authors: Sng B. L. , Sia A. T. H. , Quek K. , Woo D. , Lim Y.
Published: January 2019

This study investigated the incidence and risk factors associated with chronic pain after elective caesarean section under spinal anaesthesia in an Asian population. A prospective cohort study was conducted among subjects who underwent elective caesarean section under spinal anaesthesia, with morphine patient-controlled analgesia administered for 24 hours postoperatively. Perioperative, surgical and obstetric factors were investigated prospectively. Phone surveys were conducted to identify risk factors associated with chronic pain.

A total of 857 subjects completed both the perioperative study and phone survey. The incidence of wound scar pain for three months after surgery was 9.2% (79). Of the 51 subjects with persistent pain at the time of subsequent survey, 9.8% (n=5) had constant pain, 9.8% (n=5) had daily pain and 23.5% (n=12) had pain intermittently, at an interval of days. The independent risk factors for development of chronic pain were higher pain scores recalled in the immediate postoperative period (odds ratio [OR, 95% confidence interval] 1.348 [1.219 to 1.490], P=0.0001), pain present elsewhere (OR 2.471 [1.485 to 4.112], P=0.001) and non-private insurance status (OR 1.679 [1.034 to 2.727], P=0.036). The two most common sites of pain other than wound pain were back pain (n=316) and migraine (n=87).
Non-invasive Assessment of the Microcirculation in Critically Ill Patients
Authors: Nanas S. , Gerovasili V. , Renieris P. , Angelopoulos E. , Poriazi M. , Kritikos K. , Siafaka A. , Baraboutis I. , Zervakis D. , Markaki V. , Routsi C. , Roussos C.
Published: January 2019

Sepsis is associated with abnormalities of muscle tissue oxygenation and of microvascular function. We investigated whether the technique of near-infrared spectroscopy can evaluate such abnormalities in critically ill patients and compared near-infrared spectroscopy-derived indices of critically ill patients with those of healthy volunteers.

We studied 41 patients (mean age 58±22 years) and 15 healthy volunteers (mean age 49±13 years). Patients were classified into one of three groups: systemic inflammatory response syndrome (SIRS) (n=21), severe sepsis (n=8) and septic shock (n=12). Near-infrared spectroscopy was used to continuously measure thenar muscle oxygen saturation before, during and after a three-minute occlusion of the brachial artery via pneumatic cuff.

Oxygen saturation was significantly lower in patients with SIRS, severe sepsis or septic shock than in healthy volunteers. Oxygen consumption rate during stagnant ischaemia was significantly lower in patients with SIRS (23.9±7.7%/minute, P <0.001), severe sepsis (16.9±3.4%/minute, P <0.001) or septic shock (14.8±6%/minute, P <0.001) than in healthy volunteers (35.5±10.6%/minute). Furthermore, oxygen consumption rate was significantly lower in patients with septic shock than patients with SIRS. Reperfusion rate was significantly lower in patients with SIRS (336±141%/minute, P <0.001), severe sepsis (257±150%/minute, P <0.001) or septic shock (146±101%/minute, P <0.001) than in healthy volunteers (713±223%/minute) and significantly lower in the septic shock than in the SIRS group.

Near-infrared spectroscopy can detect tissue oxygenation deficits and impaired microvascular reactivity in critically ill patients, as well as discriminate among groups with different disease severity.
Takotsubo Cardiomyopathy during Emergence from General Anaesthesia
Authors: Meng L. , Wells C.
Published: January 2019

Takotsubo cardiomyopathy, or stress-induced cardiomyopathy, is a clinical syndrome mimicking acute myocardial infarction. We report a case of a 55-year-old man who developed Takotsubo cardiomyopathy during emergence from general anaesthesia for an elective procedure to remove a spinal cord stimulator. The perioperative state is known to induce stress, but there are few cases describing the onset of Takotsubo syndrome during this period. The case presented demonstrates that Takotsubo cardiomyopathy may occur on emergence from anaesthesia and that the pattern of left ventricular dysfunction produced may not be typical.
Comparison of the Single-use LMA Supreme with the Reusable ProSeal LMA for Anaesthesia in Gynaecological Laparoscopic Surgery
Authors: Lee A. K. Y. , Tey J. B. L. , Lim Y. , Sia A. T. H.
Published: January 2019

The Laryngeal Mask Airway Supreme (LMAS) is a new, single-use laryngeal mask airway with gastric access. We conducted a randomised controlled study comparing the LMAS with the reusable ProSeal Laryngeal Mask Airway (PLMA) in 70 patients undergoing general anaesthesia with paralysis for gynaecological laparoscopic surgery. Our primary outcome measure was the oropharynegal leak pressure. We also compared the two devices for ease of insertion, adequacy of ventilation and incidence of complications. Both devices had similar rates of successful insertion at the first attempt (LMAS 94% vs PLMA 91%). There was no difference in the time to establish an effective airway (LMAS 25±22 vs PLMA 24±9 seconds), although gastric tube insertion was faster for the LMAS (5±1 vs 7±3 seconds, P <0.001). The mean oropharyngeal leak pressure in the LMAS was significantly lower than in the PLMA (27.9±4.7 vs 31.7±6.3 cmH2O, P=0.007). This was consistent with a lower maximum tidal volume achieved with the LMAS (481±76 vs 515±63 ml, P=0.044). We found that after 60 minutes the cuff pressure was significantly higher in the PLMA (110±21 vs 57±8 cmH2O, P <0.001). There was no difference in the ability to provide adequate ventilation and oxygenation during anaesthesia. Complication rates were similar. We conclude that the oropharyngeal leak pressure and the maximum achievable tidal volume are lower with the LMAS than with the PLMA.
Intraoperative Airway Foreign Body Migration in a Child
Authors: Sharma P. , Kumar A. , Kumar A.
Published: January 2019

We report successful anaesthetic management of a foreign body in the airway, which migrated intraoperatively from one bronchus to the other causing life-threatening hypoxaemia.
A Randomised, Single-blind, Controlled Trial of Silicone Disposable Laryngeal Masks during Anaesthesia in Spontaneously Breathing Adult Patients
Authors: Williams D. L. , Wong S. M. , Pemberton E. J. , Webb T. G. , Alexander K. D.
Published: January 2019

We hypothesised that two new silicone disposable laryngeal mask airways, Meditech Systems Limited (MSL) and ProAct (PA), would perform similarly to the Classic™ Laryngeal Mask Airway (cLMA) in spontaneously breathing adult patients. One hundred and twenty consecutive adult patients were prospectively enrolled and randomly allocated to one of three groups (PA, MSL, cLMA). All patients received a standardised anaesthetic and insertion technique. The overall success rates were 97.5% for all three masks, with one failure of laryngeal mask airway insertion in each group. There was no statistical difference in airway sealing pressures between the PA laryngeal mask airway (17.9±5.9 cmH2O), MSL laryngeal mask airway (18.5±6.9 cmH2O) and cLMA (17.6±5.6 cmH2O) (P=0.816). There was no statistical difference in insertion times, ease of insertion, cuff pressure and cuff volumes. The MSL and PA disposable laryngeal mask airways provided comparable airway sealing pressures to the reusable cLMA.
Comparison of Equipotent Doses of Ropivacaine-fentanyl and Bupivacaine-fentanyl in Spinal Anaesthesia for Lower Abdominal Surgery
Authors: Koltka K. , Uludag E. , Senturk M. , Yavru A. , Karadeniz M. , Sengul T. , Ozyalcin S.
Published: January 2019

The aim of this randomised, double-blind study was to compare equipotent doses of plain ropivacaine and bupivacaine (19.5 mg and 13 mg respectively), both with fentanyl 20 μg, for spinal anaesthesia in lower abdominal surgery.

After written informed consent had been obtained, 52 ASA I to II male patients scheduled for lower abdominal surgery were randomly assigned to receive intrathecal plain ropivacaine 19.5 mg with fentanyl 20 μg (group R, n=26) or plain bupivacaine 13 mg with fentanyl 20 μg (group B, n=26) in 3 ml. The level and duration of sensory block, intensity and duration of motor block, time to mobilise and patient satisfaction were recorded.

All patients achieved sensory block to T10 or higher. The level of sensory block was significantly higher in group B (T4 [T3 to T7] vs T7 [T4 to T9], P <0.05). There was no difference in the onset time of motor block. The duration of motor block (Bromage score >0) was shorter in group R (139±39 minutes vs group B 182±46 minutes, P <0.05). The duration and intensity of complete motor block (Bromage score=3) were also shorter in group R (90±25 minutes vs 130±40 minutes, P <0.05).

We conclude that plain ropivacaine 19.5 mg plus fentanyl 20 μg is associated with a lower level of sensory block and a shorter duration of motor block when compared to bupivacaine 13 mg plus fentanyl 20 μg for spinal anaesthesia in lower abdominal surgery.
Thyroid Storm Presenting as Intra-abdominal Sepsis with Multi-organ Failure Requiring Intensive Care
Authors: Karanikolas M. , Velissaris D. , Karamouzos V. , Filos K. S.
Published: January 2019

Thyroid storm is a rare but life-threatening condition manifesting with several clinical presentations. Atypical thyroid storm should be part of the differential diagnosis in patients with multiple organ dysfunction of unknown aetiology.

In this case report, delayed recognition of thyroid storm in a young female who presented with acute abdomen increased the risk of poor outcome. Prompt initiation of anti-thyroid therapy once the diagnosis of thyroid storm was established, combined with adequate vital organ support using a goal-directed therapy protocol in the intensive care unit resulted in a good outcome.