bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Comparative Effects of Propofol versus Thiopentone on Left Ventricular Function during Electroconvulsive Therapy
Authors: Kadoi Y. , Saito S. , Ide M. , Toda H. , Sekimoto K. , Seki S. , Takahashi K. , Goto F. 
Published: January 2019

The purpose of this study was to compare the effect of propofol versus thiopentone on haemodynamics during electroconvulsive therapy (ECT), as estimated by echocardiography. Twenty-eight ASA 1 or 2 patients scheduled for ECT were randomly divided into two groups, to receive propofol 1 mg/kg (propofol group, n=14) or thiopentone 2 mg/kg (thiopentone group, n=14). Bilateral ECT was performed after the administration of propofol or thiopentone, succinylcholine and following assisted mask ventilation with 100% oxygen. Cardiac function was examined by transthoracic echocardiography, prior to induction of anaesthesia and throughout ECT until ten minutes after the seizure. In the propofol group, increased end-systolic area (ESA) and decreased fractional area change (FAC) were observed at one minute after the electrical shock compared with the awake condition. In the thiopentone group, increased ESA and decreased FAC were observed from one to three minutes after the electrical shock compared with the awake condition. There was no statistically significant change in after load in the propofol group during the study. In contrast, increased after load was observed from one to three minutes after the electrical shock in the thiopentone group (awake condition, 26±7 mmHg/cm 2 [mean±SD]; one minute after ECT, 42±7*; two minutes after ECT, 44±6*; three minutes after ECT; 40±5*, respectively)(*P<0.05). We concluded that a lesser haemodynamic change occurs after propofol anaesthesia (1 mg/kg) compared with thiopentone anaesthesia (2 mg/kg) during ECT.
Levobupivacaine versus Racemic Bupivacaine in Spinal Anaesthesia for Urological Surgery
Authors: Lee Y. Y. , Muchhal K. , Chan C. K. 
Published: January 2019

Racemic bupivacaine is the most common local anaesthetic used intrathecally. This prospective, randomized, double-blind study compared the clinical efficacy and motor block of 0.5% levobupivacaine with 0.5% racemic bupivacaine in spinal anaesthesia for urological surgery. The surgery required an upper level of sensory block of at least the tenth thoracic dermatome. Fifty patients were recruited (levobupivacaine group n=24; bupivacaine group n=26). Spinal anaesthesia was achieved with 2.6 ml of study solution injected in the subarachnoid space at the lumbar 3/4 interspace. One patient from the levobupivacaine group was excluded due to technical failure. There were no significant differences between the two groups in the quality of sensory and motor block or in haemodynamic change. Anaesthesia was adequate and patient satisfaction good in all cases. We conclude that 0.5% levobupivacaine can be used as an alternative to 0.5% racemic bupivacaine in spinal anaesthesia for surgery when a sensory block to at least T10 is required.
Post Anaesthesia Care Unit Discharge: A Clinical Scoring System versus Traditional Time-based Criteria
Authors: Truong L. , Moran J. L. , Blum P. 
Published: January 2019

This prospective cohort analysis compared the efficiency of time-based discharge criteria (Group 1) to a modified clinical scoring system (Group 2), incorporating the assessment of pain and temperature, in the post anaesthesia care unit (PACU). Two consecutive series of patients (n=292) were assessed following general anaesthesia for various surgical procedures. The time taken for patients to satisfy their respective discharge criteria was recorded as PACU length of stay (LOS). Patient group and other factors that may have influenced PACU-LOS were examined using time-to-event analysis. The raw PACU-LOS was not shown to be different between the two groups (log rank test, P=0.12). Covariate adjusted estimates were used to compare the two discharge criteria and also to identify other factors influencing PACU-LOS. The Cox regression model was poorly specified and a log-logistic accelerated failure time model was found to be the most parsimonious predictive model. Predictors of decreased PACU-LOS were the treatment group (Group 2 versus Group 1) and the covariate recording anaesthetic airway choice (no endotracheal tube (ETT) versus ETT). Surgical time, as a linear function, intra- and postoperative opioid administration, as well as postoperative antiemetic use were predictors of increased PACU-LOS. Patient age, gender, urgency of surgery, and ASA classification were not predictive of PACU-LOS. Using covariate adjusted estimates, the new PACU discharge criteria, based on the Aldrete's scoring system, was associated with a significantly reduced PACU-LOS in comparison with time-based criteria.
An Evaluation of the Modified Airway Management Device
Authors: Chiu C. L. , Wang C. Y. 
Published: January 2019

This is a preliminary report on the use of the modified Airway Management Device in 50 spontaneously breathing patients undergoing elective day care surgery. We were successful in establishing a clear airway in all 50 patients, 46 of these patients had a patent airway on the first attempt. All patients were successfully managed with the Airway Management Device throughout the surgery. Partial airway obstruction during maintenance of anaesthesia occurred in three cases requiring only minor manipulations. Our result showed that the Airway Management Device may be used as an alternative airway management in anaesthesia.
Patient-controlled Epidural Analgesia following Combined Spinal-epidural Analgesia in Labour: The Effects of Adding a Continuous Epidural Infusion
Authors: Missant C. , Teunkens A. , Vandermeersch E. , Van De Velde M. 
Published: January 2019

Patient-controlled epidural analgesia (PCEA) is used to maintain epidural analgesia following initial intrathecal analgesia. This trial investigated whether a continuous background infusion with PCEA provides superior analgesia to PCEA alone among patients who received combined spinal-epidural (CSE) analgesia during labour. Eighty parturients were randomized to either PCEA alone (PCEA) or PCEA with a background infusion of ropivacaine 0.15% with sufentanil 0.75 μg/ml at 2 ml/h (PCEA+CEI). PCEA settings were a bolus of 4 ml of the same analgesic solution with a lockout interval of 15 minutes. Significantly more patients in the PCEA group required at least one anaesthetist intervention for breakthrough pain (27 [71%] vs 10 [25%] in the PCEA+CEI group, P<0.05). Consumption of local anaesthetic (excluding manually administered boluses) was similar between the groups. If anaesthetist-administered boluses were included, more local anaesthetic was consumed by the PCEA group (47.1±19.4 mg vs 35.6±12.0 mg in the PCEA+CEI group, P<0.05). We conclude that PCEA with a background infusion provides effective analgesia with less anaesthetist workload and reduced local anaesthetic consumption as compared with PCEA without a background infusion.
The Relationship between Oxygenator Exhaust Pco2 and Arterial Pco2 During Hypothermic Cardiopulmonary Bypass
Authors: Graham J. M. , Gibbs N. M. , Weightman W. M. , Sheminant M. R. 
Published: January 2019

During cardiopulmonary bypass the partial pressure of carbon dioxide in oxygenator arterial blood (Paco2) can be estimated from the partial pressure of gas exhausting from the oxygenator (PEco2). Our hypothesis is that PEco2 may be used to estimate Paco2 with limits of agreement within 7 mmHg above and below the bias. (This is the reported relationship between arterial and end-tidal carbon dioxide during positive pressure ventilation in supine patients.) During hypothermic (28-32°C) cardiopulmonary bypass using a Terumo Capiox SX membrane oxygenator, 80 oxygenator arterial blood samples were collected from 32 patients during cooling, stable hypothermia, and rewarming as per our usual clinical care. The Paco2 of oxygenator arterial blood at actual patient blood temperature was estimated by temperature correction of the oxygenator arterial blood sample measured in the laboratory at 37°C. PEco2 was measured by connecting a capnograph end-to-side to the oxygenator exhaust outlet. We used an alpha-stat approach to cardiopulmonary bypass management. The mean difference between PEco2 and Paco2 was 0.6 mmHg, with limits of agreement (±2 SD) between -5 to +6 mmHg. PEco2 tended to underestimate Paco2 at low arterial temperatures, and overestimate at high arterial temperatures. We have demonstrated that PEco2 can be used to estimate Paco2 during hypothermic cardiopulmonary bypass using a Terumo Capiox SX oxygenator with a degree of accuracy similar to that associated with the use of end-tidal carbon dioxide measurement during positive pressure ventilation in anaesthetized, supine patients.
Assessment of Diaphragmatic Function with Cervical Magnetic Stimulation in Critically Ill Patients
Authors: Buscher H. , Valta P. , Boie T. , Hinz J. , Moerer O. , Sydow M. , Mudaliar M. Y. , Burchardi H. 
Published: January 2019

The objective of this study was to evaluate a non-volitional measurement to assess diaphragmatic function in intubated and mechanically ventilated patients in a prospective pilot interventional clinical trial. The study was conducted in an 18-bed postoperative intensive care unit based at a university hospital. Patients were prospectively assigned to two groups. Group 1 consisted of eight patients with ventilator weaning failure. Group 2 consisted of eight intubated and ventilated patients who were studied shortly after major surgery and were successfully extubated thereafter. The twitch pressure response after cervical magnetic stimulation of the phrenic nerves was measured at the endotracheal tube at different PEEP levels. In group 2 the twitch transdiaphragmatic pressure, defined as the difference between twitch gastric and twitch oesophageal pressure was also evaluated. In group 1 the mean twitch pressure at the endotracheal tube on PEEP 0, 5 and 10 cmH2O was 5.2, 4.5 and 2.6 cmH2O: In group 2 this was significantly higher (15.1 cmH2O on PEEP 0 and 12.2 cmH2O on PEEP 5). A good correlation was found between twitch diaphragmatic pressure and twitch pressure at the endotracheal tube (r2=0.96) and between twitch oesophageal pressure and twitch pressure at the endotracheal tube (r2=0.98). Patients with weaning failure have significantly lower twitch pressure at the endotracheal tube suggesting diaphragmatic dysfunction. Twitch pressure at the endotracheal tube may be a useful parameter to screen for diaphragmatic dysfunction in intubated critically ill patients. Further studies are needed to confirm these preliminary findings.
An Audit of Morphine versus Fentanyl as an Adjunct to Ropivacaine 0.2% for High Thoracic Epidural Analgesia
Authors: Royse C. F. , Royse A. G. , Deelen D. A. 
Published: January 2019

When used as an adjunct to local anaesthetic, opioid administered via the epidural route can improve the quality of analgesia. Reports of respiratory depression associated with epidural morphine use as a sole agent in the 1980s led to an increased use of lipophilic opioids, especially fentanyl. Although fentanyl is commonly used, controversy exists about its efficacy and site of action. It is possible that low-dose morphine may be more effective than fentanyl, without increasing the risk of respiratory depression. A retrospective audit was conducted of 200 consecutive patients undergoing coronary artery bypass surgery who received high thoracic epidural analgesia. One hundred patients who received fentanyl 2 μg/ml with 0.2% ropivacaine, prior to a change in our technique, were audited, followed by 100 patients who received 20 μg/ml morphine with 0.2% ropivacaine. Outcome measures included the incidence of Visual Analogue Score (VAS) ≥4/10; infusion rate adjustments; and side-effects. Patients receiving fentanyl were more likely to experience pain ≥4/10 (P'=0.002); the infusion rate was higher (P8=0.024); required more rate adjustments (P8=0.001); a greater need for noradrenaline (P'=0.001) and antiemetic drugs (P'=0.001). There were no significant differences between the groups for sedation scores or the incidence of respiratory depression. This audit suggests morphine 20 μg/ml may be superior to fentanyl 2 μg/ml, as an adjunct to 0.2% ropivacaine. We found a reduced number of infusion interventions and less inadequate patient analgesia.
Estimate of the Number of Patients Eligible for Treatment with Drotrecogin Alfa (Activated) Based on Differing International Indications: Post-hoc Analysis of an Inception Cohort Study in Australia and New Zealand
Authors: Finfer S. , Felton T. , Blundell A. , Lipman J. ,   The Anzics Clinical Trials Group Sepsis Investigators, Davies Andrew , MacArthur Colin , Newby Lynette , Bellomo Rinaldo , Wise Donna , Reece Graham , hawker Felicity , Soloveychik Lorisa , Nicholls James , Henderson Seton , Hunt Tamara , Bersten Andrew , Green David , Richards Brent , Green Stuart , Solano Tom , Flabouris Arthas , Joyce Chris , Limpus Anthony , Lipman Jeff , Turner Andrew , Finfer Simon , Szachin Vlad , Magnaye Maria , Dobb Geoff , MacKenzie Eileen , morris Gordon , Mitchell Imogen , van Heerden Vernon , Roberts Brigitte , O'leary Michael , Myburgh John , French Craig 
Published: January 2019

We aimed to estimate the potential number of patients eligible for treatment with drotrecogin alfa (activated) when applying different international criteria. The study was a post-hoc analysis of inception cohort study of 691 patients with severe sepsis during 5878 consecutive intensive care unit admission episodes in 23 closed multi-disciplinary ICUs of 21 hospitals (16 tertiary and 5 university-affiliated) in Australia and New Zealand. Outcomes assessed were presence of contraindications to treatment with drotrecogin alfa (activated), an admission APACHE II score of 25 or greater and dysfunction of two or more organs. During 5878 consecutive intensive care admission episodes, 691 patients had severe sepsis, 553 (80.0%, 95% CI 77.0–83.0%) had no relative or absolute contraindication, 64 (9.3%, 7.1–11.4%)) had a relative contraindication and 74 (10.7%, 8.4–13.0%) had an absolute contraindication. Two hundred and six patients (3.5%, 3.0–4.0%) had an APACHE II score of 25 or greater, 452 (7.7%, 7.0–8.4%) had dysfunction of two or more organs, 469 (8.0%, 7.3–8.7%) had either dysfunction of two or more organs or an APACHE II score of 25 or greater. Relatively few patients had an absolute contraindication to treatment with drotrecogin alfa (activated). Selection based on the APACHE II score results in fewer eligible patients than selection based on multiple organ dysfunction. Depending on the selection criteria used, for every hundred admissions to intensive care, between 3.5 and 8.0 of patients may be eligible for treatment with drotrecogin alfa (activated).
Relative Adrenal Insufficiency in Etomidate-Naïve Patients with Septic Shock
Authors: Jones D. , Hayes M. , Webb S. , French C. , Bellomo R. 
Published: January 2019

A recent study reported that 77% of patients with septic shock had relative adrenal insufficiency. However, all patients were mechanically ventilated and received high-dose inotropes. In addition, at least 24% had prior exposure to etomidate, a drug known to suppress adrenal function. We studied the incidence of relative adrenal insufficiency in etomidate-naïve patients with septic shock by analysing the adrenal response to high-dose short synacthen test in 113 consecutive patients from three university-affiliated intensive care units in Australia. Patients were allocated to three groups according to severity of illness and inclusion criteria of the trial of low dose hydrocortisone supplementation using information from patient records. Of the 113 patients, 98 had septic shock (Group A). The incidence of relative adrenal insufficiency in this sub-population was 24.5%. Eighty-one per cent of patients with septic shock were mechanically ventilated (Group B). In this group, the incidence of relative adrenal insufficiency was 27.8%. Only 38 of the 98 patients with septic shock (39%) fulfilled inclusion criteria for the steroid supplementation trial (Group C). In this group, the incidence of relative adrenal insufficiency was only 34.2%. In all groups its presence was associated with a higher mortality. We conclude that the incidence of relative adrenal insufficiency in etomidate-naïve septic shock patients was lower than observed in the steroid supplementation trial. Further, in those who fulfilled inclusion criteria for the trial, the incidence of relative adrenal insufficiency was half that reported by the trial. Our observations raise concerns about the generalizability of the findings of the above trial to etomidate-naïve patients.
Thrombogenic Side-Effects of Recombinant Factor VIIa after use in Coronary Artery Bypass Surgery
Authors: White M. C. , Pryn S. J. , Monk C. R. 
Published: January 2019

Recombinant activated factor VII (rFVIIa) has been used ‘off licence’ to successfully treat bleeding and reduce transfusion requirements in complex cardiac surgery. However, concerns over thrombogenic side-effects have limited but not excluded its use in patients undergoing coronary artery bypass surgery (CABG). We present two cases of CABG (one ‘on pump’ and one ‘off pump’) which were complicated by intraoperative aortic dissection and severe bleeding. In both cases the bleeding was successfully treated with rFVIIa. However the first case suffered from severe postoperative arrhythmias, myocardial infarction, cardiac arrest and worsening left ventricular dysfunction, suggesting graft patency may have been impaired, whereas the second case remained symptom-free suggesting graft patency was unaffected by the use of rFVIIa. If rFVIIa is needed to treat bleeding during CABG surgery, it may be more appropriate to administer smaller, repeated doses to minimize the risk of thrombosis and early graft failure.
The Impact of Bispectral Index Monitoring on Sedation Administration in Mechanically Ventilated Patients
Authors: Weatherburn C. , Endacott R. , Tynan P. , Bailey M. 
Published: January 2019

The aim of this prospective randomised controlled trial was to assess the effectiveness of the Bispectral Index (BIS) monitor in supporting clinical sedation management decisions in mechanically ventilated intensive care unit patients. Fifty adult mechanically ventilated surgical and general intensive care unit patients receiving sedative infusions of morphine and midazolam were randomly allocated to receive BIS monitoring (n=25) or standard sedation management (n=25). In the BIS group, sedation was titrated to maintain a BIS value of greater than 70. In the standard management group, sedative needs were titrated based on subjective assessment and clinical signs. There was no statistically significant difference in the amount of sedation administered (morphine P =0.67 and midazolam P =0.85). However, there was a statistically significant difference in sedation administration over time. Patients in the BIS group received increasing amounts of sedation over time whilst those in the control group received decreasing amounts of sedation over time. The same inverse relationship existed for both sedative agents (morphine P=0.005, midazolam P=0.03). Duration of mechanical ventilation was comparable in the two groups. We conclude that the use of BIS monitoring did not reduce the amount of sedation used, the length of mechanical ventilation time or the length of ICU stay.
Continuous Venovenous Haemofiltration Using a Citrate Buffered Substitution Fluid
Authors: Schmitz M. , Taskaya G. , Plum J. , Hennersdorf M. , Sucker C. , Grabensee B. , Hetzel G. R. 
Published: January 2019

Different methods of regional anticoagulation using citrate in continuous renal replacement therapy have been described in the past. However, these procedures were usually very complex or did not reach modern requirements for effective continuous renal replacement therapy. Furthermore, little is known about long-term acid-base stability and citrate levels during the treatment. We describe a system in which citrate is used both as anticoagulant and as the sole buffer substance in continuous venovenous haemofiltration. Our citrate-containing, calcium-free substitution fluid was used in predilution mode with a constant ratio between blood flow (120 to 150 ml/min) and substitution flow (2400 to 3000 ml/hour). Anticoagulation was limited to the extracorporeal circuit. Twenty patients with acute renal failure on mechanical ventilation were treated, four for eight hours, four for 24 hours and 12 as long they needed continuous renal replacement therapy (9.6 ± 5.0 days, range 4.0 to 39.3 days). We achieved stable acid-base and electrolyte balance in all patients. We observed no bleeding complications (patient activated clotting time 112.4±17.1 s, post-filter circuit activated clotting time 270.5 ± 80.3 s) and achieved appropriate filter life times (48.6 ± 13.2 h). Predilution, citrate-based substitution fluid provides both anticoagulation within the extracorporeal circuit and control of acid-base balance in critically ill patients at risk of bleeding in acute renal failure. It is easy to apply and safe. Clearance can be varied as long as a constant ratio between blood and substitution flow is maintained.
A Clinician's Guide to Predicting Fluid Responsiveness in Critical Illness: Applied Physiology and Research Methodology
Authors: Sturgess D. J. , Joyce C. , Marwick T. H. , Venkatesh B. 
Published: January 2019

Intravenous fluid administration is often used in critical care with the goal of improving haemodynamics and consequently tissue perfusion and oxygen delivery. While inotropic and vasoactive drugs are often necessary to correct haemodynamic instability, resuscitation usually begins with fluid therapy. As fluid challenge can result in clinical deterioration, the ability to predict haemodynamic response is desirable. In this way it might be possible to avoid unnecessary volume replacement in critically ill patients. Cardiac preload is a concept that accounts for the relationship between ventricular filling and stroke volume. It has been challenging to apply this concept to clinical practice. For this reason, the study of fluid responsiveness is of increasing research and clinical interest. The clinical application of predicting fluid responsiveness requires an understanding of relevant physiological principles. Furthermore, an improved understanding of these principles should assist the clinician in appraising published data, which has been characterised by significant methodological differences. This review aims to assist the clinician by detailing the physiological principles that underlie the prediction of fluid responsiveness in the critically ill. In addition, the potential importance of methodological differences in the current literature will be considered.