bluuebunny/crossref_metadata_2025_split huggingface dataset:
Continuing Education and New Zealand Anaesthetists: An Analysis of Current Practice and Future Needs
Authors: Weller J. , Harrison M. 
Published: January 2019

A survey of Continuing Medical Education (CME) of New Zealand anaesthetists was undertaken to identify current patterns of participation, usefulness of different activities, evidence of effectiveness, motivators and barriers to participation and to define future CME needs. The response rate was 74% and showed high levels of participation in a range of CME activities. Ratings for usefulness differed significantly between these activities. Respondents identified specific changes they had made to their practice as a result of CME, providing strong evidence for its effectiveness. Anaesthetists valued interactive methods of learning that were relevant to clinical practice. The most commonly reported motivators for participation were accreditation requirements and keeping up to date, while other work commitments were the commonest impediment. In this survey, interactive educational interventions were seen as useful, a finding consistent with systematic reviews of the effectiveness of CME in changing physician behaviour. Such reviews conclude that there is no evidence that conferences are effective in changing physician behaviour, yet respondents to this survey attributed many changes in practice to their attendance at a conference. Analysis of the needs of NZ anaesthetists supports increasing the number of workshops and interactive sessions and promoting smaller meetings and practice-based activities. The survey provides a basis for designing a future program of CME for New Zealand.
Evaluation of the Intubating Laryngeal Mask Airway™ Used by Occasional Intubators in Simulated Trauma
Authors: Reeves M. D. , Skinner M. W. , Ginifer C. J. 
Published: January 2019

This observational study assessed the potential role of the intubating laryngeal mask airway (ILMA™ ) for use by emergency care givers with limited laryngoscopy skills. Six ambulance officers with advanced airway training, five doctors with intubation experience and five doctors without intubation experience were given a short instruction course on the use of the ILMA. They subsequently used the device on 80 consenting subjects anaesthetized for elective surgery after the application of cricoid pressure and manual in-line stabilization of the cervical spine. All patients were successfully ventilated via the ILMA. Mean (SD) times in seconds to ventilation were 27 (10), 33 (18) and 47 (22) respectively in the occasional intubator ambulance officers, occasional intubator doctor and naï ve intubator groups. The numbers (percentage) failures to intubate via the ILMA in each group were 2 (7%), 5 (20%) and 4 (16%) respectively. Mean (SD) times in seconds to intubation were 32 (23), 32 (17) and 36 (25). There was no evidence of “learning” with repeated use. The feedback forms were strongly supportive of a prehospital trial and also of having an ILMA available during all intubations. Participants almost universally rated the ILMA as easy to use. This study supports further evaluation of the ILMA in a large pre-hospital trial.
Skin Temperature during Sympathetic Block: A Clinical Comparison of Bupivacaine 0.5% and Ropivacaine 0.5% or 0.75%
Authors: Filippo A. Di , Natale V. , Del Po F. , Ciapetti M. , Bressan F. , Falchi S. 
Published: January 2019

Measurement of skin temperature can be used as an indicator of sympathetic blockade induced by neuraxial anaesthesia. The aim of the study was to test the skin temperature response to epidural administration of bupivacaine and different concentrations of ropivacaine. Forty-eight ASA class I-II patients undergoing herniorraphy were enrolled into a prospective, randomized, double-blind clinical trial. Patients were randomly allocated to receive epidural anaesthesia with a single dose of 18 ml of bupivacaine 0.5% (n=16); ropivacaine 0.5% (n=16), or ropivacaine 0.75% (n=16). A temperature probe was positioned on the skin of the thigh and skin temperature registered before epidural anaesthesia, every 10 minutes for the first hour after the epidural injection and every hour for the following four hours. Sensory blockade was assessed by pinprick and motor blockade using the Bromage scale. No significant difference was observed in sensory or motor blockade. A skin temperature rise of 1 to 1.8°C compared with basal values was observed in all patients within the first hour. Temperature returned to basal values within four hours in the ropivacaine 0.5% group, within five hours in the ropivacaine 0.75% group, and remained 1°C higher after five hours in the bupivacaine 0.5% group (P<0.01). The duration of sympathetic block is significantly shorter with ropivacaine than with bupivacaine.
Unplanned Admission to the Intensive Care Unit in Postoperative Patients—An Indicator of Quality of Anaesthetic Care?
Authors: Piercy M. , Lau S. , Loh F. , Reid D. , Santamaria J. , Mackay P. 
Published: January 2019

As a clinical indicator, unplanned admission to the Intensive Care Unit from the operating room has been thought to reflect the quality of anaesthesia care intraoperatively. To explore this concept, we examined all such admissions at three hospitals over a three-month period. Cases were classified according to the Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM) classification system and an assessment was made as to whether the admission was inevitable or not. Demographic data were collected as well as co-morbidities, severity of illness, length of stay, discharge functional status and destination. There were 165 admissions identified: 55.8% were male, the median age was 63.5 years (range 15–90). There were 24 in-hospital deaths: 151 patients suffered serious morbidity or mortality. In 32 patients (19.4%), the morbidity or mortality was considered at least partially anaesthetic-related, and in 20 (12.1 %), under the control of the anaesthetist. There were 28 admissions (17.0%) with a further 9 anaesthetic-related admissions (5.5%) which were considered potentially avoidable. Avoidable anaesthetic-related admissions were due to drug overdosage (5 cases), drug error (1 case), problems relating to preoperative assessment (1 case), aspiration (1 case) and pulmonary oedema (1 case). These findings suggest that unplanned admission to the Intensive Care Unit from the operating room is not a satisfactory indicator of quality of care by the anaesthesia team. This indicator appears to represent mainly the surgical and medical conditions of the patients, and their complications. Only one in twenty unplanned admissions in this series were potentially avoidable due to complications of the anaesthetic or the postoperative analgesia.
Clonidine as an Analgesic Adjuvant to Continuous Paravertebral Bupivacaine for Post-thoracotomy Pain
Authors: Bhatnagar S. , Mishra S. , Madhurima S. , Gurjar M. , Mondal A. S. 
Published: January 2019

We prospectively evaluated the effect of Clonidine as an adjuvant to bupivacaine for continuous paravertebral intercostal nerve block, measuring pain and sedation scores and pulmonary function tests. Thirty patients scheduled to undergo thoracotomy were randomized to receive either a bolus of 0.125% bupivacaine 2 mg/kg (group BUP) or 0.125% bupivacaine 2 mg/kg with Clonidine 2 μg/kg (group BUP+CLO), followed by an infusion of 0.125% bupivacaine at 0.5 mg/kg/h, or 0.125% bupivacaine at 0.5 mg/kg/h with Clonidine at 2 μg/kg/h, in respective groups, through a paravertebral intercostal catheter. Haemodynamic parameters, pain and sedation scores and pulmonary function tests were recorded at 6, 12, 24 and 48 hours after arrival in postoperative care unit. There were significantly lower pain scores at rest and on coughing in group BUP+CLO compared with group BUP (P<0.01). Multiple comparisons revealed a significant reduction in pain score at each time point (P<0.01), except at 12h to 24h, in group BUP+CLO. Sedation scores were significantly higher in group BUP+CLO compared with group BUP at each time point (all P<0.01). There was a linear effect of time on sedation score in group BUP whereas in group BUP+CLO, the effect was quadratic. Patients in the Clonidine group had a higher incidence of hypotension (P<0.01). There was no significant difference in pulmonary function between the groups. We conclude that using Clonidine as an adjunct to bupivacaine for continuous paravertebral intercostal nerve block improves pain relief after thoracotomy, but hypotension and sedation are adverse effects interfering with its clinical application.
The Margin of Safety of a Left Double-Lumen Tracheobronchial Tube Depends on the Length of the Bronchial Cuff and Tip
Authors: Partridge L. , Russell W. J. 
Published: January 2019

The left tracheobronchial double-lumen tube is the commonest device to separate the left and right lungs for differential ventilation. With the appropriate tube, the left bronchial cuff is positioned in the bronchus so that the cuff is beyond the carina but the tip of the tube does not occlude the aperture of the left upper lobe bronchus. The difference between the length of the left main bronchus and the length of the cuff and tip of the bronchial segment of the tube has been termed “the margin of safety” by Benumof. If the length of the cuff plus the tip exceeds that of the left main bronchus, there will be occlusion of the left upper lobe bronchus. The bronchial cuff and bronchial tip lengths were measured on two hundred and twenty left tracheobronchial (double-lumen) tubes from four manufacturers. The largest cuff-tip length was 40 mm with a Portex 41Fr tube but some 41Fr tubes from all manufacturers had cuff-tip lengths of 33 mm or greater which exceed the length of the shortest left main bronchus measured by Benumof. There was also a marked variation in cuff-tip lengths of the same size tube from the same manufacturer. The largest variation was 18 mm for the Portex 41 but substantial variation of 8 mm or more was found in at least one French size of all manufacturers. Users must be aware that significant cuff-tip length variation occurs and match the selected tube to the patient to ensure an adequate margin of safety.
Acute Pulmonary Embolectomy Three Days following a Coronary Artery Bypass Graft Procedure
Authors: Kuklinski D. , Tevaearai H. T. , Eckstein F. S. , Carrel T. P. 
Published: January 2019

Pulmonary embolism is very rarely reported early after cardiac surgery, most probably due to full heparinisation during cardiopulmonary bypass. We report a 66-year-old man without thromboembolic history who presented three days after a coronary artery bypass grafting procedure with acute dyspnoea and haemodynamic instability. A CT scan confirmed paracentral bilateral pulmonary embolism requiring an urgent and successful embolectomy. Review of the literature confirms that pulmonary embolism may occur in up to 3% of post-cardiopulmonary bypass patients. The possibility of pulmonary embolism must be taken into consideration in post-cardiopulmonary bypass patients with acute onset of chest pain and respiratory insufficiency.
Stability of the Strong Ion Gap versus the Anion Gap over Extremes of PCO2 and pH
Authors: Morgan T. J. , Cowley D. M. , Weier S. L. , Venkatesh B. 
Published: January 2019

The strong ion gap (SIG) is under evaluation as a scanning tool for unmeasured ions. SIG is calculated by subtracting [buffer base], which is ([A-]+[HCO3-]), from the apparent strong ion difference, which is ([Na+] + [K+]+[Ca++]+[Mg++]-[Cl-]-[L-lactate]). A- is the negative charge on albumin and phosphate. We compared the pH stability of the SIG with that of the anion gap (AG). In normal and hypoalbuminaemic hyperlactaemic blood, PCO2 was reduced stepwise in vitro from >200 mmHg to < 20 mmHg, with serial blood gas and electrolyte analyses, and [albumin] and [phosphate] measurement on completion. Respective [haemoglobin], [albumin], [phosphate] and [lactate] in normal blood were 156 (0.9) g/l, 44 (2) g/l, 1.14 (0.06) mmol/l and 1.7 (0.8) mEq/l, and in hypoalbuminaemic blood 116 (0.9) g/l, 24 (2) g/l, 0.78 (0.06) mmol/l and 8.5 (0.5) mEq/l. pH increased from <6.85 to >7.55, causing significant falls in [Na+] and elevations in [Cl-]. Initial and final SIG values did not differ, showing no correlation with pH. Mean SIG was 0.5±1.5 mEq/l. AG values were directly correlated with pH (normal: R2=0.51, hypoalbuminaemic: R2=0.65). Final AG values significantly exceeded initial values (normal blood: 15.9 (1.7) mEq/l versus 8.9 (1.8) mEq/l, P<0.01; hypoalbuminaemic blood: 16.5 (0.8) mEq/l versus 11.8 (2.0) mEq/l, P<0.05). We conclude that, unlike the AG, the SIG is not affected by severe respiratory acidosis and alkalosis, enhancing its utility in acid-base disturbances.
Introduction and Audit of Intravenous Paracetamol at a Tertiary Paediatric Teaching Hospital
Authors: Palmer G. M. , Chen S. P. , Smith K. R. , Hardikar W. 
Published: January 2019

Although intravenous (IV) paracetamol is an attractive analgesic, there is little information on its paediatric use. During an introduction phase with limited prescribing rights, an audit was performed to assess its use and cost impact at a tertiary paediatric centre. Patients receiving IV paracetamol prescribed by two pain specialists for restricted indications had their medical records retrospectively reviewed for age, weight, diagnosis, indications/dose for IV (and other route) paracetamol/other analgesics/antiemetics, vomiting/oral intake and liver function tests if performed. One-hundred-and-twenty-one children and five neonates received 1216 (median 8 each) doses of paracetamol IV. Audited expenditure for IV paracetamol was 3.9 times the rectal alternative ($3435 vs. $875). Indications were appropriate, with 97% of patients nil oral, 41% vomiting, 17% having rectal route replaced and 3% avoiding parenteral morphine. Only five patients received incorrect dosing: three through prescription errors and two as guideline deviations; none were considered dangerous. No liver function test derangements could be directly attributed to paracetamol. This data facilitated our application to extend prescribing rights for IV paracetamol within our institution. As there is limited information or local experience with the use of IVparacetamol in paediatric settings in Australia, our data may be of use to other centres considering the introduction of the IV form of this agent.
Atrial Fibrillation in a Tertiary Care Multidisciplinary Intensive Care Unit—Incidence and Risk Factors
Authors: Arora S. , Lang I. , Nayyar V. , Stachowski E. , Ross D. L. 
Published: January 2019

Atrial fibrillation is a common arrhythmia in an intensive care unit. We performed a prospective observational study over a period of three months, to study the incidence, risk factors and outcome of patients who develop atrial fibrillation in a multidisciplinary intensive care unit. All patients above the age of 50 years were eligible. Exclusion criteria were: cardiac or oesophageal surgery during current hospitalisation, atrial fibrillation at admission, implanted pacemaker and expected intensive care unit stay of less than 24 hours. Sixty-one patients were included in the study. Eighteen patients (29.5%, confidence interval 18-40) developed atrial fibrillation. Incidence of atrial fibrillation was 4.02 episodes per 100 patient days. Patients who developed atrial fibrillation had higher age (71.3 years vs. 63.2 years, P=0.001), severity of illness (APACHE II 25.4 vs. 20.0, P=0.005) and sepsis at admission (9/18 vs. 9/43, P=0.01). They also had higher in-hospital mortality (Risk ratio 2.7, 95% confidence interval 1.3-5.4). Standardised mortality ratio was higher in patients who developed atrial fibrillation (1.08 vs. 0.63). Patients who developed atrial fibrillation required a longer period of mechanical ventilation and inotropic support. Multivariate logistic regression analysis showed age > 75 years, APACHE II score >20 and sepsis at admission were independent predictors for development of atrial fibrillation in critically ill patients. Although atrial fibrillation by itself is unlikely to be the cause of higher mortality, it is likely to be a marker for increased mortality and resource utilisation in the intensive care unit.
Effects of Reduction of the Caudal Morphine Dose in Paediatric Circumcision on Quality of Postoperative Analgesia and Morphine-Related Side-Effects
Authors: Cesur M. , Alici H. A. , Erdem A. F. , Yapanoglu T. , Silbir F. 
Published: January 2019

This study compared the efficacy and adverse effects of three low doses of morphine (10, 15 and 30 μg.kg1) for caudal epidural analgesia in children undergoing circumcision. A total of 135 boys undergoing outpatient circumcision were randomly assigned to receive 10, 15 or 30 μg.kg1 of caudal morphine. Anaesthesia was induced and maintained with propofol. After induction, the morphine was added to 0.5 ml.kg1 1% lignocaine solution with adrenaline 5μg.ml1 and injected caudally. Anaesthesia quality, postoperative pain and adverse events in a 24-hour period were evaluated. Paracetamol (20 mg. kg’ orally) was used as rescue analgesia as required. No patient required paracetamol in the first eight hours after the caudal injections. In the first 24 hours postoperatively no further analgesia was required in 66.7%, 77.8% and 91.1% of the patients in the 10, 15 and 30 μg.kg1 groups, respectively (P=0.01 for 10 vs. 30 groups). All patients had excellent analgesia. No respiratory complications were observed. Nausea-vomiting occurred in 13.3%, 20% and 46.7% of the patients in the 10, 15 and 30 μg.kg1 groups (P=0.002 for 10 vs. 30 and 0.044 for 15 vs. 30). Pruritus occurred in 8.9%, 11% and 15.6% in the 10, 15 and 30 μg.kg1 groups but was localised and did not require treatment. This study was not powered to assess concerns that low dose epidural morphine may rarely be associated with delayed apnoea and is therefore considered unsuitable for outpatient use in many centres. Increases in caudal morphine dose above 10 μxg. kg1 produce some ‘paracetamol sparing’ but no improvement in analgesia, some pruritus and a significant increase in nausea and vomiting.
Prediction of Successful Defibrillation in Human Victims of Out-of-Hospital cArdiac Arrest: A Retrospective Electrocardiographic Analysis
Authors: Ristagno G. , Gullo A. , Berlot G. , Lucangelo U. , Geheb F. , Bisera J. 
Published: January 2019

In the present study we sought to examine the efficacy of an electrocardiographic parameter, ‘amplitude spectrum area’ (AMSA), to predict the likelihood that any one electrical shock would restore a perfusing rhythm during cardiopulmonary resuscitation in human victims of out-of-hospital cardiac arrest. AMSA analysis is not invalidated by artefacts produced by chest compression and thus it can be performed during CPR, avoiding detrimental interruptions of chest compression and ventilation. We hypothesised that a threshold value of AMSA could be identified as an indicator of successful defibrillation in human victims of cardiac arrest. Analysis was performed on a database of electrocardiographic records, representing lead 2 equivalent recordings from automated external defibrillators including 210 defibrillation attempts from 90 victims of out-of-hospital cardiac arrest. A 4.1 second interval of ventricular fibrillation or ventricular tachycardia, recorded immediately preceding the delivery of the shock, was analysed using the AMSA algorithm. AMSA represents a numerical value based on the sum of the magnitude of the weighted frequency spectrum between two and 48 Hz. AMSA values were significantly greater in successful defibrillation (restoration of a perfusing rhythm), compared to unsuccessful defibrillation (P <0.0001). An AMSA value of 12 mV-Hz was able to predict the success of each defibrillation attempt with a sensitivity of 0.91 and a specificity of 0.97. In conclusion, AMSA analysis represents a clinically applicable method, which provides a realtime prediction of the success of defibrillation attempts. AMSA may minimise the delivery of futile and detrimental electrical shocks, reducing thereby postresuscitation myocardial injury.
Arterial Gas Embolism: A Review of Cases at Prince of Wales Hospital, Sydney, 1996 to 2006
Authors: Trytko B. E. , Bennett M. H. 
Published: January 2019

Arterial gas embolism may occur as a complication of diving or certain medical procedures. Although relatively rare, the consequences may be disastrous. Recent articles in the critical care literature suggest the non-hyperbaric medical community may not be aware of the role for hyperbaric oxygen therapy in non-diving related gas embolism. This review is part of an Australian appraisal of experience in the management of arterial gas embolism over the last 10 years. We identified all patients referred to Prince of Wales Hospital Department of Diving and Hyperbaric Medicine with a diagnosis of arterial gas embolism from 1996 to 2006. Twenty-six patient records met our selection criteria, eight iatrogenic and 18 diving related. All patients were treated initially with a 280 kPa compression schedule. At discharge six patients were left with residual symptoms. Four were left with minor symptoms that did not significantly impact quality of life. Two remained severely affected with major neurological injury. Both had non-diving-related arterial gas embolism. There was a good outcome in the majority of patients who presented with arterial gas embolism and were treated with compression.
The Pulmonary Artery Catheter in Australasia: A Survey Investigating Intensive Care Physicians’ Knowledge and Perception of Future Trends in Use
Authors: Johnston I. G. , Fraser J. F. , Sabapathy S. , Kruger P. S. 
Published: January 2019

A survey was conducted to assess the knowledge and trends of use of the pulmonary artery catheter amongst intensive care practitioners in Australasia. A 31-item multiple choice questionnaire, identical to one previously trialled in studies in the United States and Europe, was distributed to all registered intensive care specialists and trainees working in intensive care units in Australasia. Five-hundred-and-forty-one questionnaires were distributed and 151 (27.9%) were returned, with an average mark of 82.7%±9.3% and a range of 53.3 to 100%. Total score was significantly associated with years of experience in intensive care (P <0.04), number of pulmonary artery catheters inserted (P <0.015) and whether or not the respondent had passed the Joint Faculty of Intensive Care Medicine examination (P <0.01). Scores were significantly higher amongst trainees (P <0.0001) and physicians who had passed the Joint Faculty of Intensive Care Medicine examination (P <0.0001). Overall, 44.9% of respondents indicated their use of the pulmonary artery catheter was decreasing, with 42.6% indicating their use was the same over the past five years. Sixty-one percent of respondents indicated they either agreed or strongly agreed with the statement that the use of echocardiography should supersede the use of the pulmonary artery catheter by intensive care specialists in the future. We concluded that in this study, knowledge of the pulmonary artery catheter and its use is better in Australasia than in previous studies in North America and Europe. The majority of respondents in Australasia believe that echocardiography will supersede the use of the pulmonary artery catheter in the future.