bluuebunny/crossref_metadata_2025 huggingface dataset:
Remifentanil vs. Lignocaine for Attenuating the Haemodynamic Response during Rapid Sequence Induction Using Propofol: Double-Blind Randomised Clinical Trial
Authors: Kim J.-T. , Shim J.-K. , Kim S. H. , Ryu H.-G. , Yoon S.-Z. , Jeon Y. S. , Bahk J.-H. , Kim C.-S.
Published: January 2019

This study was conducted to determine whether lignocaine or remifentanil effectively attenuate the response to endotracheal intubation during rapid sequence induction. Forty-eight patients were randomly divided into three groups: Group NS (n=16) received normal saline 0.1 ml/kg, Group L (n=16) received lignocaine 1.5 mg/kg, and Group R (n=16) received remifentanil 1 /μg/kg. Anaesthesia was induced with propofol 2 mg/kg after glycopyrrolate 0.2 mg IV. Each study drug was given intravenously over 30 seconds after loss of consciousness. Cricoid pressure was applied until intubation. Succinylcholine 1.0 mg/kg was administered to facilitate tracheal intubation. After intubation, the patient's lungs were ventilated with sevoflurane 1% and nitrous oxide 50% in oxygen. Mean arterial pressure and heart rate were recorded before induction, at loss of consciousness, immediately before laryngoscopy and every minute after intubation for 10 minutes. Mean arterial pressure fell following propofol in all groups. The maximum increase in mean arterial pressure in Group NS and Group L were 46% and 38% respectively above the baseline value one minute after intubation, whereas the mean arterial pressure in Group R increased only back to the baseline value. Heart rate in Group NS and Group L were increased by 27% and 33% above baseline value respectively one minute after intubation, while that in Group R was increased only to the baseline value. The results indicate that remifentanil 1 μg/kg, but not lignocaine 1.5 mg/kg, effectively attenuates the haemodynamic response to endotracheal intubation during rapid sequence induction using propofol.
Long-Term Neurological Complications Associated with Surgery and Peripheral Nerve Blockade: Outcomes after 1065 Consecutive Blocks
Authors: Watts S. A. , Sharma D. J.
Published: January 2019

Peripheral nerve blockade is gaining popularity as an analgesic option for both upper or lower limb surgery. Published evidence supports the improved efficacy of regional techniques when compared to conventional opioid analgesia. The incidence of neurological deficit after surgery associated with peripheral nerve block is unclear. This paper reports on neurological outcomes occurring after 1065 consecutive peripheral nerve blocks over a one-year period from a single institution. All patients receiving peripheral nerve blocks for surgery were prospectively followed for up to 12 months to determine the incidence and probable cause of any persistent neurological deficit. Formal independent neurological review and testing was undertaken as indicated. Thirteen patients reported symptoms that warranted further investigation. A variety of probable causes were identified, with peripheral nerve block being implicated in two cases (one resolved at nine months and one remaining persistent). Overall incidence of block-related neuropathy was 0.22%.

Persistent postoperative neuropathy is a rare but serious complication of surgery associated with peripheral nerve block. Formal follow-up of all such blocks is recommended to assess causality and allow for early intervention.
Ultrasound Quantification of Anterior Soft Tissue Thickness Fails to Predict Difficult Laryngoscopy in Obese Patients
Authors: Komatsu R. , Sengupta P. , Wadhwa A. , Akça O. , Sessler D. I. , Ezri T. , Lenhardt R.
Published: January 2019

Morbid obesity is associated with difficult laryngoscopy and intubation. In the general population, bedside indices for predicting difficult intubation (i.e. Mallampati classification, thyromental distance, sternomental distance, mouth-opening and Wilson risk score) have poor-to-moderate sensitivity (20-62%) and moderate-to-fair specificity (82-97%). In the obese population, although the risk of difficult intubation after a positive Mallampati test is 34%, it is still not sufficient to be used as a single predictive test. An abundance of pretracheal soft tissue anterior to the vocal cords, as quantified by ultrasound, was a better predictor of difficult laryngoscopy than body mass index (BMI) in Israeli patients. Obesity is a growing problem in the United States: therefore we sought to confirm this finding in the obese population in the United States. We used ultrasound to quantify the neck soft tissue, from the skin to the anterior aspect of the trachea at the vocal cords, in 64 obese patients (BMI >35). We assessed thyromental distance, mouth-opening, jaw movement, limited neck mobility, modified Mallampati score, abnormal upper teeth, neck circumference, confirmed obstructive sleep apnoea, BMI, age, race and gender as predictors. Twenty patients were classified as difficult laryngoscopy; they were older (47±9 vs 42±1 years; P=0.048; mean±SD) and had less soft pretracheal tissue (20.4±3.0 vs 22.3±3.8 mm; P=0.049) than did easy laryngoscopy patients. Multivariate regression indicated that none of the factors was an independent predictor of difficult laryngoscopy. We conclude that the thickness of pretracheal soft tissue at the level of the vocal cords is not a good predictor of difficult laryngoscopy in obese patients in the United States.
The Accuracy of Surrogate Decisions in Intensive Care Scenarios
Authors: Li L. L. M. , Cheong K. Y. P. , Yaw L. K. , Liu E. H. C.
Published: January 2019

Critically ill patients are often unable to make decisions about life-sustaining treatments and surrogate decisionmakers are relied upon. However, it is unclear how accurately the surrogates’ decisions reflect patients’ intentions and expectations.

We interviewed 36 pairs of patients and their appointed surrogate decision-makers about their decisions regarding nine treatments in each of three scenarios. The scenarios were persistent vegetative state, coma with likely neurological damage and chronic disease with dementia. The patients were interviewed 24 hours after they had undergone elective surgery under general anaesthesia. The surrogates were interviewed separately by the same interviewer.

There was poor agreement between decisions made by the patients and their surrogates. The patients’ and surrogates’ summary scores (median (interquartile range) [range]) for treatments were 0 (0-4) [0-9] vs 8 (0-9) [0-9] for the vegetative state scenario, 3 (0-9) [0-9] vs 9 (0-9) [0-9] for the coma scenario and 3 (0-9) [0-9] vs 9 (4-9) [0-9] for the chronic disease scenario. The significantly higher surrogate scores suggest that the surrogates’ decisions would have resulted in the patients having far more treatment than the patients would have wanted.

In our participants, there was poor agreement between the decisions made by surrogates and patients. Further study is needed on measures such as facilitated discussions, advance directives and the difficulties that surrogates face, in order to improve the accuracy of surrogates’ decisions and respect of patients’ autonomy.
Survival and Quality of Life after Prolonged Intensive Care Unit Stay
Authors: Rimachi R. , Vincent J. -L. , Brimioulle S.
Published: January 2019

There are few data on long-term outcomes in mixed groups of intensive care unit (ICU) patients with prolonged stays. We evaluated the relationship between length of stay in the ICU and long-term outcome in all patients admitted to our 31-bed department of medico-surgical intensive care over a one-year period who stayed in the department for more than 10 days (n=189, 7% of all ICU admissions). Mortality increased with length of stay from 1 to 10 days (1 day 5%, 5 days 15%, 9 days 24%, 10 days 33%) but remained stable at about 35% for longer ICU stays. In the long-stay patients, the most common reasons for ICU admission were intracranial bleeding (23%), polytrauma (14%), respiratory failure (13%) and septic shock (11%). The main reasons for prolonged ICU stay were ventilator dependency (40%), infectious complications (23%) and coma (16%). Long-stay patients had a 65% ICU survival, 55% hospital survival and 37% one-year survival. At one-year follow-up, 73% of surviving patients reported no or minor persistent physical complaints compared to before the acute illness; 27% had a major functional impairment, including 8% who required daily assistance. In conclusion, in ICU patients, mortality increases with length of stay up to 10 days. Patients staying in the ICU for more than 10 days have a relatively good long-term survival. Most survivors have an acceptable quality of life.
Medical specialist examinations: Item format types and minimising error
Authors: Jones R. W.
Published: January 2019

Examinations such as those within anaesthesia and intensive care are used to identify candidates who are able to progress through their training programs or on to specialist practice. Examinations that are valid, reliable, fair, practical and generalisable are useful tools for determining the underlying anaesthesia and intensive care related abilities of candidates. However, medical specialty examinations are only indirect indicators of candidate competency or mastery. It is possible for error to enter examination decision making and to adversely affect examination processes and results. This article presents an effective method for viewing examination content, procedures and processes for the purposes of minimising error. The article also describes the six question (or item) formats currently utilised within the examinations used by the Australian and New Zealand College of Anaesthetists and/or the Joint Faculty of Intensive Care Medicine. The article includes summaries of the advantages and disadvantages of each of these formats.
Acute Respiratory Distress in a Bleomycin Primed Patient: A New Use for Nitric Oxide
Authors: Holley A. , Cartner M. , Lipman J.
Published: January 2019

We describe the use of nitric oxide as an oxygen-sparing strategy in the context of prior bleomycin exposure. A 27-year-old male, previously treated with bleomycin for a testicular germ cell tumour, presented with severe acute respiratory distress syndrome on the second postoperative day following an extensive retroperitoneal dissection. The mechanism of bleomycin toxicity and potential benefits of nitric oxide in this situation are considered.
Long-Term Respiratory Support in Children with Giant Omphalocele
Authors: Edwards E. A. , Broome S. , Green S. , Douglas C. , Mccall E. , Nuthall G. , Nixon G. M.
Published: January 2019

Omphalocele is one of the most common fetal abdominal wall defects. When this defect is of giant size, significant respiratory compromise may occur and impact on prognosis. We present three infants with giant omphalocele, highlighting the potential need for ongoing ventilatory support after the neonatal period in children born with this condition. The three cases had very different outcomes but all had significant ventilatory insufficiency and required substantial respiratory support at least into the second year of life. The possibility of a requirement for long-term ventilatory support should be discussed with families at antenatal diagnosis. A conservative surgical approach, together with early monitoring for hypoventilation and screening for the development of pulmonary hypertension is indicated for these children to limit morbidity. We suggest early tertiary respiratory input and advocate for a specific case manager to oversee the regional care of these children.
Paradoxical Vocal Cord Motion—a Dangerous Imitator of Airway Emergencies
Authors: Harmon A. , Khursandi D. C. S.
Published: January 2019

We report a case of stridor in a 32 year old woman. Initial laryngoscopy demonstrated adduction of the vocal cords on inspiration, which reverted to abduction on induction of general anaesthesia. The airway was structurally normal. The most likely diagnosis was paradoxical vocal cord motion, a condition in which psychological stress can precipitate respiratory symptoms and signs due to involuntary adduction of the vocal cords during inspiration. Its importance to the anaesthetist lies in its ability to masquerade as a serious airway or respiratory condition.
Ascites Misdiagnosed as a Left Pleural Effusion during Cardiac Surgery: Case Report and Suggested Echocardiographic Features to Differentiate These Entities
Authors: Jackson A. H.
Published: January 2019

The spleen and ascitic fluid are rarely imaged by transoesophageal echocardiography. In this case perisplenic ascitic fluid was misdiagnosed as a left pleural effusion and led to unnecessary surgical opening of the left pleural space during aortic valve replacement. On review of the images, three features were found that differentiated perisplenic ascitic fluid from a left pleural effusion. First, the spleen has a uniformly homogeneous, echogenic appearance (unlike atelectatic lung). Second, perisplenic ascitic fluid can be seen to communicate with a lateral space (unlike pleural fluid). Third, perisplenic ascitic fluid lies entirely lateral to the descending aorta (unlike pleural fluid).
Purpura Fulminans Associated with Lactobacillus paracasei Liver Abscess
Authors: Burns D. , Hurst J. R. , Hopkins S. , Patch D. , Burroughs A. K. , Agarwal B.
Published: January 2019

Purpura fulminans is a rare but devastating haemorrhagic condition often associated with sepsis. Many different organisms have been implicated in the aetiology of purpura fulminans, most commonly Neisseria meningitidis and Streptococcus pneumoniae. We report a case of purpura fulminans associated with Lactobacillus paracasei liver abscess. Purpura fulminans has not previously been associated with this organism and specific bacteriological testing was used to exclude the presence of other species.
Adult Klippel-Feil Syndrome: Haemodynamic Instability in the Prone Position and Postoperative Respiratory Failure
Authors: Teoh D. C. A. , Williams D. L.
Published: January 2019

A 52-year-old patient with Klippel-Feil syndrome was scheduled for elective C1 dorsal laminectomy and occipitocervical stabilisation under general anaesthesia. Preoperatively she had bulbar symptoms and a history of recurrent aspiration pneumonia, but no evidence of cardiovascular disease. When she was turned prone she developed persistent tachycardia, hypotension and ST segment changes despite fluids, pressors and inotropes. Her condition improved when turned supine, but she had persistent ECG changes and a troponin rise was measured the following day. She was extubated two days postoperatively but aspirated again and subsequently died 12 days later from respiratory failure. If prone positioning is required in patients with Klippel-Feil syndrome we suggest meticulous positioning to avoid sternal compression of the heart. We also suggest thorough preoperative respiratory evaluation and elective postoperative intensive care as these patients are at high risk of developing postoperative respiratory failure.
Transtracheal Lignocaine: Effective Treatment for Postextubation Stridor
Authors: Lewis K. E.
Published: January 2019

Three cases of postextubation stridor due to suspected laryngospasm are described in which a small dose of lignocaine injected intra-tracheally, through the cricothyroid membrane, produced rapid and effective relief of stridor with no early recurrence or side-effects. The procedure was performed safely and quickly and was well tolerated by patients. Transtracheal injection of local anaesthetic should be considered for treatment of postextubation stridor in adults, so long as there is no risk of pulmonary aspiration, and pathological causes of laryngospasm have been excluded.
Comparison of Potency of Ephedrine and Mephentermine for Prevention of Post-Spinal Hypotension in Caesarean Section
Authors: Mohta M. , Agarwal D. , Gupta L. K. , Tyagi A. , Gupta A. , Sethi A. K.
Published: January 2019

The dosages and potency of intravenous mephentermine for prevention of post-spinal hypotension are not available in English literature. This study was designed to determine the minimum effective dose (ED 50 ) of mephentermine and to compare its potency with that of ephedrine for prevention of post-spinal hypotension in parturients undergoing caesarean section. Dixon's up-down method of sequential allocation was used for vasopressor doses. Following administration of spinal anaesthesia, patients received a prophylactic infusion with 50 mg infused over a period of 30 minutes as the initial dose and dose intervals of 5 mg, of either ephedrine or mephentermine. The ED 50 of ephedrine was 25.0 mg (95% CI 15.5 to 40.4 mg). For mephentermine, the up-down method was abandoned due to the success of the minimum dose possible but the ED 50 appeared to be less than 5 mg. In conclusion, the minimum effective dose of mephentermine is much less than that of ephedrine for prevention of post-spinal hypotension. Another trial with a lower starting dose and smaller dose interval of mephentermine is required to determine the potency ratio of mephentermine and ephedrine.
The Effect of Aprotinin on Risk of Acute Renal Failure Requiring Dialysis after On-Pump Cardiac Surgery
Authors: Raajkumar A. , Ho K. M. , Cokis C. , Slade N.
Published: January 2019

The use of aprotinin in cardiac surgery to reduce perioperative bleeding and transfusion is controversial. We assessed the effect of aprotinin on the risk of acute renal failure in 423 patients who underwent on-pump cardiac surgery between January 1, 2005 and December 31, 2006. Of these 423 patients, 318 (75.2%) received aprotinin (median dose=3.0 million KIU, standard deviation=2.8 million KIU; interquartile range: 2 million KIU to 4 million KIU). Aprotinin was more likely to be used in patients who did not cease aspirin before surgery, in urgent or emergency surgery, who had impaired left ventricular function, a longer period of bypass and aortic cross-clamp time, and with both coronary artery bypass graft and valvular surgery performed. The overall incidence of acute renal failure requiring dialysis was 2.8%. The use of aprotinin was not associated with a reduction in transfusion nor an increased risk of renal failure requiring dialysis, atrial fibrillation, cerebrovascular accident or mortality in the univarate analyses. In the multivariate analysis, only preoperative serum creatinine concentration (odds ratio [OR] 1.06 per 10 μmol/l increment in creatinine, 95% confidence interval [CI]: 1.01 to 1.14, P=0.029) and urgency of the surgery (urgent vs. scheduled surgery: OR 12.8, CI: 2.3 to 70.8, P=0.004; emergency vs. scheduled surgery: OR 23.1, CI: 3.0 to 180.2, P=0.003) were significantly associated with an increased risk of acute renal failure requiring dialysis. The use of low-dose aprotinin did not significantly reduce perioperative transfusion requirements and was not a significant risk factor for acute renal failure requiring dialysis in our patients.
Preoperative Assessment for Obstructive Sleep Apnoea and the Prediction of Postoperative Respiratory Obstruction and Hypoxaemia
Authors: Blake D. W. , Chia P. H. , Donnan G. , Williams D. L.
Published: January 2019

Patients scheduled for elective surgery requiring general anaesthesia and hospital admission were assessed for risk of obstructive sleep apnoea (OSA) using history, body mass index and upper airway examination to determine any relation between OSA risk and the rate of respiratory events after surgery. Anaesthesia and postoperative analgesia were at the discretion of the treating anaesthetist, who was made aware of any suspicion of OSA. Respiratory monitoring for apnoeas (central or obstructive), hypopnoeas and oxygen desaturations was continuous for a 12-hour period on the first postoperative night. We used automated analysis and visual scanning of respiratory recordings, but sleep stages were not assessed. Patients classified as OSA risk had more respiratory obstructive events per hour than controls (38±22 vs. 14±10) and an increased proportion of the 12-hour monitored period with oxygen saturation <90% (7±12% vs. 2±5% of the 12-hour period). Perioperative morphine dose was predictive of central apnoeas for both OSA risk and control patients (P=0.002). This study suggests that preoperative suspicion of OSA should lead to increased postoperative monitoring and efforts to minimise sedation and opioid dose. It also supports the routine use of supplemental oxygen with patient-controlled opioid analgesia.
Noradrenaline Use is Not Associated with Extubation Failure in Septic Patients
Authors: Teixeira C. , Tonietto T. Frederico , Gonçalves S. Cadaval , Cremonese R. Viegas , De Oliveira R. Pinheiro , Savi A. , Oliveira E. Silvestre , Alves F. André Cardona , Brodt S. Fernando Monteiro , Barth J. Hervê Diel , Machado A. Santana , de Campos Balzano P. , Maccari J. Gasparetto , da Silva N. Brandão
Published: January 2019

Standard clinical practice recommends minimal doses of vasoactive drugs during weaning of patients from mechanical ventilation. However, there are currently no clinical data to inform clinicians about whether the use of noradrenaline during weaning predisposes to weaning failure. The objective of this study was to evaluate whether the necessity of the vasopressor noradrenaline in mechanically ventilated patients recovering from septic shock changed the extubation outcome.

A total of 656 patients recovering from septic shock on mechanical ventilation were selected from intensive care units in two university hospitals. Patients receiving noradrenaline at the time of weaning and case-controls not taking noradrenaline were matched for age, gender, haemodynamic and ventilatory parameters, aetiology of respiratory failure and APACHE II score. One hundred and forty-five patients who successfully tolerated a spontaneous breathing trial were extubated while on noradrenaline therapy and the reintubation rate was measured.

In the noradrenaline group, the mean dose of noradrenaline during initial shock treatment was 0.52±0.29 μg/kg/min and 0.12±0.10 μg/kg/min during weaning. The reintubation rate was 12/63 (19%) in the noradrenaline group and 15/82 (18.3%) in the control group (P=1.00). Intensive care unit mortality was also similar in both groups (10/63, 15.9%) for noradrenaline patients and (11/82, 13.4%) for control patients (P=0.81). Arterial blood gases and ventilatory and haemodynamic parameters were similar in all patients regardless of weaning success.

We did not find that the use of noradrenaline at the time of weaning was associated with extubation failure. Low doses of noradrenaline may not preclude weaning from mechanical ventilation.
Identification of Genetic Mutations in Australian Malignant Hyperthermia Families Using Sequencing of Ryr1 Hotspots
Authors: Gillies R. L. , Bjorksten A. R. , Davis M. , Du Sart D.
Published: January 2019

Advances in analysis of the RYR1 gene (which encodes the skeletal muscle ryanodine receptor) show that genetic examination is a useful adjunct to the in vitro contracture test in the diagnosis of malignant hyperthermia, as defects in RYR1 have been shown to be responsible for malignant hyperthermia susceptibility. DNA from 34 malignant hyperthermia susceptible individuals and four malignant hyperthermia equivocal subjects was examined using direct sequencing of ‘hotspots’ in the RYR1 gene to identify mutations associated with malignant hyperthermia. Seven different causative mutations (as defined by the European Malignant Hyperthermia Group) in nine malignant hyperthermia susceptible individuals were identified. In another six malignant hyperthermia susceptible individuals, five different published but as yet functionally uncharacterised mutations were identified. A further three as yet unpublished and functionally uncharacterised (novel) mutations were identified in three malignant hyperthermia susceptible samples. If the novel and previously published mutations prove to be functionally associated with calcium homeostasis, then this method of analysis achieved a mutation detection rate of 47%. Based on the number of relatives presenting to our unit in the study period, the muscle biopsy rate would have decreased by 25%. That we only identified a genetic defect in RYR1 in 47% of in vitro contracture test positive individuals suggests that there are other areas in RYR1 where pathogenic mutations may occur and that RYR1 may not be the sole gene associated with malignant hyperthermia. It may also reflect a less than 100% specificity of the in vitro contracture test.
The Accuracy of Reporting of General Anaesthesia for Childbirth: A Validation Study
Authors: Roberts C. L. , Ford J. B. , Lain S. , Algert C. S. , Sparks C. J.
Published: January 2019

Administrative population health data, such as hospital discharge data, are a potentially valuable resource for determining anaesthesia and analgesia use in childbirth at a population level. However, the reliability of general anaesthesia reporting is unknown. This study aimed to determine the accuracy of the reporting of peripartum general anaesthesia in single and linked population health data. Data from a statewide validation study of 1200 women provided the gold standard for delivery and postpartum general anaesthesia use. The validation data were merged with both the hospital discharge and birth databases. As both of these datasets collect information on general anaesthesia, it could be reported in one, both or neither database. Among the 1184 records available for review, 7.7% of women had a general anaesthetic during the birth admission, of which 6.2% were for delivery and 1.5% were for a postpartum procedure. Reporting sensitivities ranged from 26% to 97% and specificities 94% to 100%. Identifying general anaesthesia from either the birth or hospital data improved general anaesthesia ascertainment. Limiting analysis to caesarean sections resulted in very accurate identification of general anaesthesia for delivery(sensitivity 97.0%, specificity 99.8%) while limiting to vaginal births was moderately accurate for identifying postpartum general anaesthesia (sensitivity 73.2%, specificity 99.8%). General anaesthesia for delivery is reported with a high level of accuracy in birth and linked birth-hospital data, but not in hospital discharge data alone. Population health data are a reliable source for examining general anaesthesia for delivery.
Australian Anaesthetists’ Practice of Sedation for Gastrointestinal Endoscopy in Adult Patients
Authors: Padmanabhan U. , Leslie K.
Published: January 2019

A wide spectrum of practice in sedation for gastrointestinal endoscopy in adult patients is documented overseas, but a current profile of the practice of Australian anaesthetists is unavailable. We therefore surveyed 200 Fellows of the Australian and New Zealand College of Anaesthetists on the choice of drugs and monitoring, use of analgesic throat spray and prophylactic intravenous fluids and the depth of sedation for gastrointestinal endoscopy. Our response rate was 57% and endoscopy formed a significant part of most respondents’ practices. Propofol was used for almost all procedures, in combination with midazolam alone (14%), fentanyl alone (6%), midazolam and fentanyl (61%), another drug (15%) or no adjuvant(4%). The majority of patients received prophylactic intravenous fluids for endoscopic retrograde cholangio-pancreatography (83%) and colonoscopy (64%), but not for gastroscopy (20%). All patients received supplemental oxygen and monitoring with pulse oximetry. However, over 20% of patients having gastroscopy or colonoscopy did not have noninvasive blood pressure monitoring. A maximum depth of sedation during which the patient was unresponsive to painful stimulation (commensurate with general anaesthesia) was targeted by 54% of respondents. Significant variations exist in the practice of sedation and monitoring for endoscopy in adult patients by anaesthetists in Australia.
Changes in Serum Procalcitonin and C-Reactive Protein following Antimicrobial Therapy as a Guide to Antibiotic Duration in the Critically ILL: A Prospective Evaluation
Authors: Venkatesh B. , Kennedy P. , Kruger P. S. , Looke D. , Jones M. , Hall J. , Barruel G. Ray
Published: January 2019

Serial procalcitonin is reported to be useful to titrate duration of antibiotic therapy in the non critically ill patient with pneumonia. The aim of this study was to examine the relationship between antibiotic therapy and serial serum procalcitonin concentrations in a cohort of critically ill septic patients and examine for any differences between culture positive (CP) and culture negative (CN) sepsis. Seventy-five critically ill patients with suspected sepsis were enrolled in this prospective observational study. Serial procalcitonin and C-reactive protein assays were measured on days one, three, five, seven, 10 and 14. The mean duration of antibiotic therapy was similar in the two groups (10.4±5.1 (CP) vs. 8.4±5.1 (CN) days, P=0.09). Serum procalcitonin concentrations were significantly higher at baseline in the CP than the CN group (14.9±22.9 vs. 6.8±21.5 ng/ml, P=0.04). During the study period, serum concentrations of procalcitonin and C-reactive protein declined in both groups. Serum procalcitonin consistently remained higher in the CP group (P<0.05) and did not return to normal values. In the CN group, procalcitonin concentrations fell below 0.5 only on day 10. There was no significant difference in C-reactive protein profile between the two groups. Four patients in the CP group (11%) had relapse of sepsis. The mean procalcitonins in the relapsed subgroup were lower than those in the remission subgroup (P=0.02). Therapy for proven or presumed infections was associated with declining serum procalcitonin and C-reactive protein in critically ill septic patients. The marked variability and overlap in plasma profile of these markers between CP and CN sepsis makes it difficult to define a nadir plasma concentration at which one can recommend discontinuation of antibiotic therapy.
Drug Administration Errors: A Prospective Survey from three South African Teaching Hospitals
Authors: Llewellyn R. L. , Gordon P. C. , Wheatcroft D. , Lines D. , Reed A. , Butt A. D. , Lundgrens A. C. , James M. F. M.
Published: January 2019

This prospective study was undertaken to determine the incidence of drug administration errors by anaesthetists at three tertiary South African hospitals. Hospitals A and C treat adults predominantly, whereas Hospital B is a paediatric hospital.

Anaesthetists completed an anonymous study form for every anaesthetic performed over a six-month period. They were asked to indicate whether or not an error or near-miss had occurred and if so, the details thereof.

A total of 30,412 anaesthetics were administered during the study period. The response rate and combined incidence of errors and near-misses was as follows: Hospital A 48.8% (1:320), B 81.3% (1:252) and C 48.1 % (1:250). The overall response rate was 53% and the combined incidence was 1:274. Neither the experience of the anaesthetist nor emergency surgery influenced whether an error occurred or not. Most errors occurred during the maintenance phase of anaesthesia. The most common errors were those of substitution. At the paediatric hospital, incorrect dose was as frequent an error as substitution. Of all errors, 36.9% were due to drug ampoule misidentification; of these the majority (64.4%) were due to similar looking ampoules. Another 21.3% were due to syringe identification errors. No major complication attributable to a drug administration error was reported.

Despite an increasing awareness of the problem together with suggestions in the literature to reduce the incidence, drug administration errors remain fairly common in South Africa. Failure to institute suggested solutions will continue to compromise patient safety.
The Use of “Ketofol” (Ketamine-propofol Admixture) Infusion in Conjunction with Regional Anaesthesia
Authors: Rapeport D. A. , Martyr J. W. , Wang L. P.
Published: January 2019

We present four patients in whom a “ketofol” (ketamine 200 mg and propofol 200 mg) infusion was used in conjunction with regional anaesthesia. The patients were considered ‘high risk’ due to their medical condition or age. The ketofol proved safe and effective in all four cases. Advantages of this technique included analgesia, airway preservation, maintenance of spontaneous respiration, haemodynamic stability and rapid recovery.
In Situ Simulation-based Team Training for Post-cardiac Surgical Emergency Chest Reopen in the Intensive Care Unit
Authors: Nunnink L. , Welsh A.-M. , Abbey M. , Buschel C.
Published: January 2019

Emergency chest reopen of the post cardiac surgical patient in the intensive care unit is a high-stakes but infrequent procedure which requires a high-level team response and a unique skill set. We evaluated the impact on knowledge and confidence of team-based chest reopen training using a patient simulator compared with standard video-based training. We evaluated 49 medical and nursing participants before and after training using a multiple choice questions test and a questionnaire of self-reported confidence in performing or assisting with emergency reopen.

Both video- and simulation-based training significantly improved results in objective and subjective domains. Although the post-test scores did not differ between the groups for either the objective (P=0.28) or the subjective measures (P=0.92), the simulation-based training produced a numerically larger improvement in both domains. In a multiple choice question out of 10, participants improved by a mean of 1.9 marks with manikin-based training compared to 0.9 with video training (P=0.03). On a questionnaire out of 20 assessing subjective levels of confidence, scores improved by 3.9 with manikin training compared to 1.2 with video training (P=0.002).

Simulation-based training appeared to be at least as effective as video-based training in improving both knowledge and confidence in post cardiac surgical emergency resternotomy.
A Prospective Randomised Controlled Trial of Ultrasound Guided versus Nerve Stimulation Guided Distal Sciatic Nerve Block at the Popliteal Fossa
Authors: van Geffen G. J. , van den Broek E. , Braak G. J. J. , Giele J. L. P. , Gielen M. J. , Scheffer G. J.
Published: January 2019

The direct visualisation of nerves and adjacent anatomical structures may make ultrasonography the preferred method for nerve localisation. In this prospective randomised study, we investigated whether, for distal sciatic nerve block in the popliteal fossa, an ultrasound guided technique would result in the use of less local anaesthetic without changing block characteristics and quality.

Using electrical nerve stimulation or ultrasound guidance, the nevre was identified in two groups of 20 patients scheduled for lower limb surgery. Hereafter lignocaine 1.5% with adrenaline 5 μg/ml was injected. The attending anaesthesiologist assessed the injected volume.

Significantly less local anaesthetic was injected in the ultrasound group compared to the nerve stimulation group (17 vs. 37 ml, P <0.001), while the overall success rate was increased (100% vs. 75%; P=0.017).

We conclude that the use of ultrasound localisation for distal sciatic nerve block in the popliteal fossa reduces the required dose of local anaesthetic significantly, and is associated with a higher success rate compared to nerve stimulation without changing block characteristics.
Ventilation and Weaning Practices in Australia and New Zealand
Authors: Rose L. , Presneill J. J. , Johnston L. , Nelson S. , Cade J. F.
Published: January 2019

Using a one-day prospective point prevalence design, this study aimed to characterise the current practice of mechanical ventilation and weaning in Australian and New Zealand intensive care units.

During 2005, a bi-national one-day survey of 55 intensive care units found the point-prevalence of mechanical ventilation to be 284/491(58%). Common modes used were synchronised intermittent mandatory ventilation with pressure support, pressure support ventilation (each 116/284, 41%) and pressure-control modes (48/284, 17%). Relative to volume-control modes, pressure-control was more frequently used for patients with respiratory disease (odds ratio 4.7, 95% confidence interval 2.4 to 9.2, P <0.001) or greater severity of illness (odds ratio 1.7, 95% confidence interval 1.1 to 2.6, P=0.01, per five-point increment in the maximum sequential organ failure score). Excluding cardiothoracic surgery patients, the Kaplan-Meier estimated median total ventilation duration was 1.9 days (interquartile range 0.8 to 6.8 days). Apart from 24/255 (9.4%) patients who received only pressure support ventilation, weaning methods (attempted in 255 patients, 29 prior deaths) included: change to pressure support ventilation (186/255, 73%), T-piece (31/255, 12%) or other methods (14/255, 5.5%).

The point prevalence of mechanical ventilation was greater than comparable international studies. Australian and New Zealand intensive care unit ventilatory practices are similar, but differ substantially from published international survey results, due to a near absence of assist/control, prominent use of pressure-control modes and a preference for pressure support ventilation weaning as opposed to T-piece.
Superficial Cervical Plexus Block Combined with Auriculotemporal Nerve Block for Drainage of Dental Abscess in Adults with Difficult Airways
Authors: Ling K. U. , Hasan M. Shahnaz , Ha K. O. , Wang C. Y.
Published: January 2019

We report our use of a superficial cervical plexus block to manage three adults who presented for drainage of dental abscesses. All patients had difficult airways related to severe trismus (preoperative inter-incisor distance ≤1.5 cm). The first two patients, whose abcesses involved both the submandibular and submasseteric spaces, were managed with combined superficial cervical plexus and auriculotemporal nerve block. In a third patient, a superficial cervical plexus block alone was sufficient because the abscess was confined to the submandibular region. The blocks were successful in all three cases with minimal requirement for supplemental analgesia. We recommend the consideration of superficial cervical plexus block, and if necessary an auriculotemporal nerve block, for the management of selected patients with difficult airways who present for drainage of dental abcesses.
Adenosine-induced Cardiac Standstill to Facilitate Endovascular Embolisation of Cerebral Arteriovenous Malformations in Children
Authors: Puri G. D. , Sen I. , Bapuraj J. R.
Published: January 2019

This report describes three children, aged eight to 11 years, with high-flow cerebral arteriovenous malformations who underwent interventional neuroradiological procedures involving glue (N-butyl cyanoacrylate) embolisation under general anaesthesia. The procedure was facilitated by relative hypotension induced by esmolol infusion and intravenous adenosine boluses. To allow controlled deposition of N-butyl cyanoacrylate into the arteriovenous malformations, glue injection was synchronised with the onset of adenosine-induced brief cardiac standstill. This resulted in satisfactory obliteration of the arteriovenous malformations nidus in all cases. The haemodynamic modulations, including the adenosine-induced brief cardiac standstill, was noted to not affect the BIS values in our patients. All patients had satisfactory obliteration of their arteriovenous malformations and had good neurological outcomes at one-year follow-up.
Subarachnoid Morphine, Bupivacaine and Fentanyl as Part of Combined Spinal-epidural Analgesia for Low Anterior Resection. A Prospective, Randomised, Double-blind Clinical Trial
Authors: Stamenkovic D. , Geric V. , Djordjevic M. , Raskovic J. , Slavkovic Z. , Randjelovic T. , Karanikolas M.
Published: January 2019

This study was designed to compare the efficacy of subarachnoid morphine alone or in combination with bupivacaine and fentanyl for combined spinal-epidural analgesia in colorectal surgery. This is a prospective, randomised, double-blind clinical trial. Sixty patients undergoing low anterior resection were assigned to one of three groups: subarachnoid morphine, bupivacaine and fentanyl, subarachnoid morphine and bupivacaine or subarachnoid morphine only. Epidural catheter placement and subarachnoid injection were done via a combined spinal-epidural Epistar® needle at L2-3. The epidural catheter was used for scheduled intraoperative bupivacaine and intermittent postoperative bupivacaine and morphine administration. Intraoperative epidural bupivacaine, intraoperative intravenous fentanyl use, time to first analgesia request, postoperative visual analogue scale pain scores, tramadol requirements and side-effects were recorded for 72 hours. Postoperative analgesia was comparable in all groups. Intraoperative fentanyl and bupivacaine consumption was lowest in the morphine, bupivacaine and fentanyl group. Time to first analgesia request was longer in the morphine, bupivacaine and fentanyl compared to the morphine group (P=0.009). Tramadol use was lower in the morphine and bupivacaine group compared to morphine, bupivacaine and fentanyl (P=0.017) on postoperative day two. There were no significant adverse effects. All patients ambulated the morning after surgery. The addition of bupivacaine and fentanyl to subarachnoid morphine did not confer any advantage on postoperative visual analogue scale scores and tramadol use, but lowered the need for additional intraoperative intravenous fentanyl and epidural bupivacaine and prolonged the time to first analgesia request.
Anaphylactoid Reaction to Intravenous Contrast in Patient with Systemic Mastocytosis
Authors: Weingarten T. N. , Volcheck G. W. , Sprung J.
Published: January 2019

Systemic mastocytosis is a rare disorder characterised by tissue infiltration of morphologically abnormal mast cells and has been associated with severe anaphylactoid reactions during general anaesthesia. We report the case of a 43-year-old woman who developed a severe anaphylactoid reaction to iodinated contrast media. Persistently elevated serum tryptase levels led to further evaluation and the eventual diagnosis of systemic mastocytosis. This case highlights the importance of repeated measurements of serum tryptase levels following severe anaphylactoid reactions. The anaesthetist should also be aware of the propensity of these patients to develop severe anaphylactoid reactions during general anaesthesia and use treatment strategies to minimise this risk.
Application of the Laboratory Risk Indicator in Necrotising Fasciitis (LRINEC) Score to Patients in a Tropical Tertiary Referral Centre
Authors: Holland M. J.
Published: January 2019

The objective of this study was to assess the applicability and usefulness of the Laboratory Risk Indicator in Necrotising Fasciitis (LRINEC) score in patients from our institution.

A retrospective analysis was undertaken of the case notes of all patients admitted to our facility between January 2002 and December 2005 with the admission diagnosis of necrotising fasciitis and the application of the LRINEC score upon the initial blood tests. The sensitivity, specificity and likelihood ratios were then calculated for patients with a LRINEC score of ≥6 compared with the findings of a surgical biopsy.

Twenty-eight patients were identified as having the admission diagnosis of necrotising fasciitis on the hospital database and were eligible for the study. Ten of these had biopsy-proven necrotising fasciitis.

With a cut-off score of ≥6, the LRINEC score had a sensitivity of 80%, specificity of 67%, a positive predictive value of 57% and a negative predictive value of 86% in distinguishing the patients with proven necrotising fasciitis from those with severe soft tissue infections. The likelihood ratio of a positive biopsy was 2.4 and the likelihood ratio of a negative biopsy was 0.3.

A cut-off value of ≥6 of the LRINEC score was not overly sensitive or specific, and the likelihood ratios suggest that, at this cut-off level, the LRINEC score would have only a very small effect on the post-test probability of the patients in the studied population having necrotising fasciitis.
Evidence-based Evolution of the High Stakes Postgraduate Intensive Care Examination in Australia and New Zealand
Authors: Lee R. P. , Venkatesh B. , Morley P.
Published: January 2019

The fellowship examination for intensive care medicine in Australia and New Zealand, first held in 1979, has undergone four major periods of development and change since inception. These periods are characterised as: 1. 1979 to 1996 – initiation and establishment of the exam as a relevant and comprehensive assessment process for a new specialty. 2. 1997 to 2001 – revision to increase breadth of coverage, increase reliability for a growing number of candidates and ensure that each candidate received the same exam: • Expansion: to incorporate assessment of CanMEDS skills (including communication, procedures and professional qualities). • Lengthening: to increase the number of exposures, to ensure reliability. • Quarantining of candidates: to allow the provision of a similar exam for each candidate. 3. 2002 to 2006 – increasing emphasis on examiner training, standard setting and increasing feedback to candidates to improve the educational experience and guide exam preparation. Blueprinting of questions to maintain validity. 4. 2008 onwards – logistic revision to ensure feasibility for a rapidly growing number of candidates and refinement to apply modem standard setting and quality control

The exam has been regarded as a ‘tough but fair’ assessment in its 30 years of existence and the committee overseeing its development has aimed to continually review the process to maintain those qualities as well as reliability, validity and feasibility. The increasing number of candidates has allowed accumulation of usable statistics but has tested the feasibility of running such a labour intensive exam. To date, there have been 800 presentations to the exam with 498 successful candidates.
New Insulin Analogues and Perioperative Care of Patients with Type 1 Diabetes
Authors: Killen J. , Tonks K. , Greenfield J. , Story D. A.
Published: January 2019

While insulin remains the mainstay of managing type 1 diabetes, much has changed over the last 15 years. These changes should help in managing patients with type 1 diabetes during the perioperative period. More flexible insulin therapy has three components: 1) basal, 2) prandial and 3) corrective. Many patients, particularly younger patients, are using genetically modified recombinant human insulin analogues. Two of these analogues, aspart and lispro insulin, are rapid-acting with faster onset and offset than subcutaneous regular insulin, allowing both prandial and corrective boluses. Other insulin analogues, particularly glargine and possibly detemir, have a flat profile of up to 24 hours, providing improved basal insulin delivery. Basal insulin can also be provided by a continuous subcutaneous infusion of rapid-acting insulin via a computerised pump that also provides boluses on demand. There is little evidence to help choose the best management of patients with type 1 diabetes during surgery. Some authors still recommend glucose-potassium-insulin infusions for all patients with type 1 diabetes. We challenge this approach, given the flexibility of the newer insulin analogues and delivery systems. We suggest that for many procedures, patients’ usual regimens can be maintained in the perioperative period, providing less disruption and, possibly, greater safety. Both hyperglycaemia and hypoglycaemia reflect poor management: we suggest a target glucose range of 5 to 10 mmol/l. The importance of frequently measuring blood glucose and appropriate responses cannot be overemphasised.