bluuebunny/crossref_metadata_2025_split huggingface dataset:
A Survey of the Use of Unapproved Medicines in Anaesthesia Practice in New Zealand
Authors: Julian K. A. , Stapelberg F. 
Published: January 2019

The Medicines Act (1981) and its amendments regulate the manufacture, sale and supply of medicines, medical devices and related products in New Zealand. Medications are approved for supply under the provisions of this Act. Supply and administration of unapproved medications is permitted. When this occurs, the supplier must report this to the Director-General of Health. Additionally, the patient must be informed of the unapproved status of the drug and be advised of the forwarding of information related to their health care to a third party. For apparently commercial reasons, approval has not been sought for a number of formulations of medications commonly used in anaesthesia practice. There has been no published literature of the impact of this legislation on the practice of anaesthesia in New Zealand. A survey was undertaken to determine how commonly anaesthetists administer unapproved drugs, whether the requirements for informed consent were met and any perceived impact the status of these medications has on patient care. The survey findings indicated that the majority of New Zealand anaesthetists practise ‘outside the law’ with respect to unapproved medicines. Seventy-eight percent do not inform patients about the potential use of unapproved medications during their anaesthetic, despite 65% administering these medications to patients “every few weeks” or even more often.
Generalisability of Behavioural Skills in Simulated Anaesthetic Emergencies
Authors: Weller J. M. , Jolly B. , Robinson B. 
Published: January 2019

A reliable assessment of clinical performance requires multiple cases, as performance varies between cases depending on previous experiences and knowledge of the case. However, behavioural attributes, including communication and teamwork, may be expected to be less dependent on specific case knowledge and thus be more stable across cases. This has implications for training and assessment design. In this study we measured the psychometric properties of assessment of behaviour in simulated anaesthetic emergencies. Twenty anaesthesia trainees were rated in three simulated emergencies by four assessors. The psychometric properties of scores for behaviour were determined and were compared with scores for medical management and overall performance. We found that scores for behaviour were less dependent on the specific clinical context than the scores for overall performance and medical management, implying transferability of crisis management behaviours between cases.
Adverse Physiological Events under Anaesthesia and Sedation: A Pilot Audit of Electronic Patient Records
Authors: Grant C. , Ludbrook G. , Hampson E. A. , Semenov R. , Willis R. 
Published: January 2019

Review of perioperative activity, including adverse events, throughput and compliance with ‘best practice’, can theoretically be used to optimise healthcare delivery. Computer-based analysis of electronic patient records could provide a practical means to manage quality improvement. This pilot study examined the effectiveness of such a system in practice. All intraoperative patient notes and physiological data were collected over 17 months in a rural hospital using data from an electronic record-keeping system. Algorithms were developed to automatically identify potential adverse events based on physiological measures. Each computer-identified event was reviewed by a panel of three anaesthetists and assessed for validity, severity and probable cause. Two areas were identified to pilot quality improvement activities—sedation for colonoscopies and inhalational anaesthesia with desflurane. Specific ‘inhouse’ guidelines were created for these procedures and feedback on the patterns of adverse events were provided to anaesthetic staff. A total of 138 separate adverse events were identified for all operative cases over 17 months, with an overall adverse event incidence of 3.3%. The adverse event incidence during colonoscopy and laryngospasm/hypoxia during desflurane anaesthesia was 6.3% and 1.3% respectively. This decreased to 2.8% (P <0.005) and 0.13% (P <0.0001) respectively for the nine months following feedback and the introduction of guidelines. Anaesthesia information systems can be an effective quality improvement tool and may enhance existing tools such as incident reporting systems.
Antimicrobial Effects of Two Anaesthetic Agents: Dexmedetomidine and Midazolam
Authors: Ayoglu H. , Kulah C. , Turan I. 
Published: January 2019

Some anaesthetic agents are known to inhibit microbial growth. The aim of this in vitro study was to investigate possible antimicrobial effects of two frequently used agents in intensive care units, dexmedetomidine and midazolam. Antimicrobial effect was tested on Staphylococcus aureus, Enterococcus faecalis, Escherichia coli and Pseudomonas aeruginosa by broth microdilution method. Midazolam showed inhibitor and bactericidal effect on S. aureus at concentrations 256 μg.ml -1 and 512 μgml -1 respectively and on E. faecalis at concentrations 128 μg.ml 1 and 256 μg.ml -1. Dexmedetomidine demonstrated inhibitor effect on S. aureus, E. coli and P. aeruginosa at concentrations 32 μg.ml -1, 16 μg.ml -1 and 16 μg.ml -1 respectively. Midazolam had inhibitor and bactericidal effects on S. aureus and E. faecalis. Dexmedetomidine had only inhibitor effects on S. aureus, E. coli and P. aeruginosa. Further studies are needed to determine the antimicrobial mechanisms and clinical applications.
Comparison between Sevoflurane/Remifentanil and Propofol/Remifentanil Anaesthesia in Providing Conditions for Somatosensory Evoked Potential Monitoring during Scoliosis Corrective Surgery
Authors: Fung N. Y. , Hu Y. , Irwin M. G. , Chow B. F. M. , Yuen M. Y. 
Published: January 2019

Somatosensory evoked potential (SSEP) monitoring is an important tool in spinal corrective surgery. Anaesthesia has a significant influence on SSEP monitoring and a technique which has the least and shortest suppressant effect on SSEP while facilitating a fast recovery from anaesthesia is ideal. We compared the effect of sevoflurane/remifentanil and propofol/remifentanil anaesthesia on SSEPs during scoliosis corrective surgery and assessed patients’ clinical recovery profiles. Twenty patients with idiopathic scoliosis receiving surgical correction with intraoperative SSEP monitoring were prospectively randomised to receive sevoflurane/remifentanil anaesthesia or propofol/remifentanil anaesthesia. During surgery, changes in anaesthesia dose and physiological variables were recorded, while SSEP was continuously monitored. A simulated ‘wake-up’ test was performed postoperatively to assess speed and quality of recovery from anaesthesia. The effects of propofol and sevoflurane resulted in SSEP amplitude variability between 18.0% ± 3.5% to 28.7% ± 5.9% and SSEP latency variability within 1.3% ± 0.4% to 2.6% ± 1.2%. Patients receiving sevoflurane had faster suppression and faster recovery of SSEP amplitude compared to propofol (P <0.05), although propofol anaesthesia showed less within-patient variability in Cz amplitude and latency (P <0.05). On cessation of anaesthesia, time to eye-opening (5.2 vs. 16.5 minutes) and toe movement (5.4 vs. 17.4 minutes) was shorter following sevoflurane (all P <0.05). These findings indicate that propofol produces a better SSEP signal than sevoflurane. However, adjustments in sevoflurane concentration result in faster changes in the SSEP signal than propofol. Assessment of neurological function was facilitated more rapidly after sevoflurane anaesthesia.
Effect of Recruitment and Body Positioning on Lung Volume and Oxygenation in Acute Lung Injury Model
Authors: Ryu H. G. , Bahk J.-H. , Lee H.-J. , Im J.-G. 
Published: January 2019

The mechanism of oxygenation improvement after recruitment manoeuvres or prone positioning in acute lung injury or acute respiratory distress syndrome is still unclear. We tried to determine the mechanism responsible for the effects of recruitment manoeuvres or prone positioning on lung aeration using a whole lung computed tomography scan in an oleic acid induced acute lung injury canine model. Twelve adult mongrel dogs were allocated into either the supine group (n=6) or the prone group (n = 6). After the establishment of acute lung injury, three recruitment manoeuvres were performed at one-hour intervals. Haemodynamic and ventilatory variables, arterial blood gas analyses and CT scans of the whole lung were obtained 90 minutes after oleic acid injection and five minutes before and after each recruitment manoeuvre. Recruitment manoeuvres in the supine position improved oxygenation (P=0.025) that correlated with increase of the poorly- and well-aerated dorsal (dependent) lung volume (r=0.436, P=0.016). Prone positioning increased oxygenation (P=0.004) that also correlated with increase of the poorly- and well-aerated dorsal (nondependent) lung volume (r=0.787, P <0.001). However, the recruitment manoeuvre in the prone position had no effect on oxygenation despite an increase in ventral (dependent) lung volume. The increase in PO2 after recruitment manoeuvres in the supine position or after prone positioning is related to the increase of the poorly- and well-aerated dorsal lung.
Evaluation of the Efficacy of Magnesium Sulphate as an Adjuvant to Lignocaine for Intravenous Regional Anaesthesia for Upper Limb Surgery
Authors: Narang S. , Dali J. S. , Agarwal M. , Garg R. 
Published: January 2019

Several additives have been combined with local anaesthetics for intravenous regional anaesthesia to improve block quality, analgesia and to decrease tourniquet pain. Magnesium sulphate is one potential additive. This prospective, randomised, double-blinded study was conducted in 30 ASA physical status I or II patients undergoing upper limb surgery under tourniquet. In group L, patients received intravenous regional anaesthesia with lignocaine alone (9 ml of 2% lignocaine diluted with normal saline to total volume of 36 ml). Patients in group M received intravenous regional anaesthesia with lignocaine plus magnesium sulphate (6 ml of 25% magnesium sulphate plus 9 ml of 2% lignocaine diluted with normal saline to total volume of 36 ml). Assessment was by observing the response to injection of drug; sensory and motor block and tourniquet pain. The mean time of onset of sensory block was 12.40 and 3.47 minutes in groups L and M respectively (P <0.001). The average times of onset of motor block in groups L and M were 17 and six minutes respectively (P <0.001). Of the patients in group M, 66.7% reported moderate to severe pain while the drug was being injected, compared to 20% in group L (P=0.011). There was a statistically significant difference in visual analogue scale for tourniquet pain at 10 and 30 minutes after tourniquet inflation (lower in group M). These findings indicate that magnesium sulphate added as an adjuvant to lignocaine hastens the onset of sensory and motor block and decreases tourniquet pain. However, there is increased incidence of transient pain on injection if magnesium sulphate is added.
Ocular Surface Bacterial Colonisation in Sedated Intensive Care Unit Patients
Authors: Mela E. K. , Drimtzias E. G. , Christofidou M. K. , Filos K. S. , Anastassiou E. D. , Gartaganis S. P. 
Published: January 2019

We investigated the time-dependent ocular surface bacterial colonisation of sedated patients hospitalised in an intensive care unit and aimed to evaluate whether proper topical antibiotic prophylaxis could prohibit corneal infection. The study lasted 12 months and included 134 patients undergoing sedation and mechanical respiratory support for various medical reasons. Patients hospitalised for less than seven days and those with pre-existing ocular surface pathology were excluded. All patients were examined on admission by inspecting the cornea for erosions. Follow-up examinations were performed each subsequent day. Cultures were also obtained from the conjunctival sac of both eyes on admission and every seventh day until the end of sedation. Standard laboratory techniques were used for isolation, identification and antibiotic susceptibility testing of bacteria. Antibiotic treatment for prophylaxis was administered accordingly. Analysis was carried out for 70 patients. Duration of sedation ranged from seven to 122 days. Fifty-four (77%) patients were colonised by at least one bacterial species other than normal flora within seven to 42 days. Multiple bacteria were isolated from 28 patients undergoing prolonged sedation. Prevalent isolates were Pseudomonas aeruginosa, Acinetobacter spp. and Staphylococcus epidermidis. Infectious keratitis was prohibited in all cases. Ocular surface of long-term sedated patients was found to be colonised by various bacterial species and their isolation was closely associated with the time period of hospitalisation. The results of this study suggest that the early identification of ocular surface bacteria colonisation and the administration of topical antibiotics for prophylaxis can prohibit corneal infection in these patients.
Anaesthesia for Acute Intestinal Obstruction Associated with Cerebral Arteriovenous Malformation in a Child
Authors: Scarth E. J. , White M. C. 
Published: January 2019

This case report describes the perioperative management of a child presenting with acute intestinal obstruction secondary to bowel malrotation after a recent intracranial haemorrhage associated with an intracranial arteriovenous malformation. We discuss the anaesthesia planning for this case, where the ‘optimal’ management strategies for the two conditions present are potentially conflicting. Issues include rapid sequence induction in the presence of a ruptured arteriovenous malformation, maintenance of cerebral perfusion pressure in the face of bowel ischaemia, and the use of epidural anaesthesia in a child with recent intracranial haemorrhage. Written consent was obtained from the patient and parents to publish this case.
The Safety of Recombinant Factor VIIa in Cardiac Surgery
Authors: Mitra B. , Phillips L. , Cameron P. A. , Billah B. , Reid C. 
Published: January 2019

We investigated whether there was an association between recombinant activated factor VII (rFVIIa) use in cardiac surgery and thromboembolic events by comparing cases in two medical registries. The incidence of thromboembolic events in patients undergoing cardiac surgery (except isolated coronary artery bypass grafts) who had received rFVIIa and were entered into the Australian and New Zealand Haemostasis Registry was compared with the background incidence in patients entered in the Australasian Society for Cardiac and Thoracic Surgeons database. Mortality, length of hospital stay and thromboembolic complications such as stroke, perioperative myocardial infarction and pulmonary embolism data were analysed. A total of 705 patients in the Registry were compared with 6554 patients in the Thoracic Surgeons database. The use of rFVIIa was independently associated with higher mortality (odds ratio 2.55, P <0.001) and longer hospital stay (odds ratio 1.54, P=0.020). However, multiple regression analyses showed no independent association between rFVIIa and stroke (odds ratio 1.0, P=0.994) or perioperative myocardial infarction (odds ratio 0.29, P=0.053), while the use of rFVIIa was associated with fewer pulmonary emboli (odds ratio 0.02, P <0.001). These findings indicate that patients who received rFVIIa had increased mortality and length of hospital stay, as expected, but that rFVIIa use was not associated with an increased incidence of stroke or perioperative myocardial infarction. In the absence of randomised controlled clinical trials, this analysis suggests that the off-label use of rFVIIa in cardiac surgery does not significantly increase thromboembolic events.
Eosinopenia as a Diagnostic Marker of Bloodstream Infection in Hospitalised Paediatric and Adult Patients: A Case-Control Study
Authors: Wibrow B. A. , Ho K. M. , Flexman J. P. , Keil A. D. , Kohrs D. L. 
Published: January 2019

The objective of this study was to assess whether eosinopenia was a reliable diagnostic marker of bloodstream infection in hospitalised adult and paediatric patients. The design was a case-control study, set in a tertiary adult and paediatric hospital. A total of 157 adult and 85 paediatric patients with bloodstream infection (‘cases’) were compared to 195 and 94 randomly selected adult and paediatric patients who had clinical suspicion of bloodstream infection but with a negative blood culture (‘controls’) respectively. Patients with haematological or immunosuppressive disease and control patients who were treated with antibiotics within one week prior to the blood culture were excluded. Eosinopenia, or undetectable eosinophil count (<0.01×109 or >10/mm3), was more common among the cases than the controls (46.5% vs 21.5%, respectively). The specificity of eosinopenia to predict bloodstream infection in adult patients was reasonable (79%, 95% confidence interval [CI] 74 to 82), but its sensitivity was low (47%, 95% CI 41 to 52). The absolute eosinophil count only had a modest ability to discriminate bloodstream infections from controls in adult patients (area under receiver operating characteristic curve 0.349, 95% CI 0.288 to 0.411). Eosinophil counts had very little overall predictive ability (area under receiver operating characteristic curve 0.448, 95% CI 0.363 to 0.533, P=0.237), and the sensitivity (54%, 95% CI 47 to 61) and specificity (56%, 95% CI 49 to 63) of eosinopenia to predict bloodstream infection in paediatric patients were both low. In the multivariate analyses, only C-reactive protein concentrations and neutrophil counts, but not eosinopenia, were significantly associated with the presence of bloodstream infection in both adult and paediatric patients. The presence of eosinopenia can be considered as an inexpensive warning test for bloodstream infection in hospitalised adult patients so that further investigations can be initiated. An absence of eosinopenia is, however, not sensitive enough to exclude bloodstream infection. C-reactive protein concentrations and neutrophil counts were both better markers of bloodstream infection than eosinopenia in hospitalised paediatric and adult patients.
Analysis of Human Cultured Myotubes Responses Mediated by Ryanodine Receptor 1
Authors: Kobayashi M. , Mukaida K. , Migita T. , Hamada H. , Kawamoto M. , Yuge O. 
Published: January 2019

Malignant hyperthermia is a life-threatening condition caused by autosomal dominant mutations in the ryanodine receptor type 1 gene. Identifying patients predisposed to malignant hyperthermia is done through the Ca-induced Ca release test in Japan. We examined the intracellular calcium concentration in human cultured muscle cells and compared the sensitivity of myotubes to ryanodine receptor type 1 activators based on the Ca-induced Ca release rate. We assessed the utility of this method as an identifying test for predisposition to malignant hyperthermia. Muscle specimens were obtained from 34 individuals undergoing the Ca-induced Ca release test. We cultured myotubes from residual material and monitored changes in intracellular calcium concentration after exposure to the ryanodine receptor type 1 activators caffeine, halothane and 4-chloro-m-cresol by measuring fura-2 fluorescence. We determined the half maximal effective concentrations (EC50) for the test compounds in each myotube and calculated cut-off points using receiver operating characteristic curves. Seventeen patients each were classified into the accelerated and non-accelerated groups based on their Ca-induced Ca release rate. The EC50 values for caffeine, halothane and 4-chloro-m-cresol of the accelerated group were significant lower than those of the non-accelerated group (P <0.001, P <0.001 and P <0.001, respectively). The calculated cut-off points of EC50 values for caffeine, halothane and 4-CmC were 3.62 mM, 2.28 mM and 197 μM, respectively. An increased sensitivity to ryanodine receptor type 1 activators was seen in myotubes in the accelerated group. This functional test on human cultured myotubes indicates that the alteration of their intracellular Ca2+ homeostasis may identify the predisposition to malignant hyperthermia.
Erythropoietin as a Novel Brain and Kidney Protective Agent
Authors: Moore E. M. , Bellomo R. , Nichol A. D. 
Published: January 2019

Erythropoietin is a 30.4 kDa glycoprotein produced by the kidney, which is mostly known for its physiological function in regulating red blood cell production in the bone marrow. Accumulating evidence, however, suggests that erythropoietin has additional organ protective effects, which may specifically be useful in protecting the brain and kidneys from injury. Experimental evidence suggests that these protective mechanisms are multi-factorial in nature and may include inhibition of apoptotic cell death, stimulation of cellular regeneration, inhibition of deleterious pathways and promotion of recovery. In this article we review the physiology of erythropoietin, assess previous work that supports the role of erythropoietin as a general tissue protective agent and explain the mechanisms by which it may achieve this tissue protective effect. We then focus on specific laboratory and clinical data that suggest that erythropoietin has a strong brain protective and kidney protective effect. In addition, we comment on the implications of these studies for clinicians at the bedside and for researchers designing controlled trials to further elucidate the true clinical utility of erythropoietin as a neuroprotective and nephroprotective agent. Finally, we describe EPO-TBI, a double-blinded multi-centre randomised controlled trial involving the authors that is being conducted to investigate the organ protective effects of erythropoietin on the brain, and also assesses its effect on the kidneys.
Observational Study of Anaesthetists’ Fresh Gas Flow Rates during Anaesthesia with Desflurane, Isoflurane and Sevoflurane
Authors: Dexter F. , Maguire D. , Epstein R. H. 
Published: January 2019

Reducing excessive fresh gas flow rates (FGF) is an established and simple strategy to reduce the administration of volatile anaesthetic agents. We studied clinicians’ FGF use to understand better why two previous clinical trials achieved significant reductions in FGF by using feedback to anaesthetists. Anaesthesia information management system data from a US academic medical centre were analysed retrospectively. One year of data starting from July 2008 had 11,170 cases. Fresh gas flow rates were measured each minute during cases. Anaesthetists were more likely to choose FGF of multiples of 1 l/minute and 0.5 l/minute than random. However, the pattern was too inconsistent to be of economic or psychological importance and thus is not needed when describing a target FGF. Cumulative distributions of FGF were shifted to the left for desflurane and isoflurane compared to sevoflurane (i.e. cost comparisons among agents may need to use different target FGF). Variation in mean FGF among anaesthetists was small. Even if all anaesthetists had identical mean FGF, the standard deviation of FGF among cases would be reduced by less than 0.1 l/minute for all agents. Most of the achievable reductions in FGF were small reductions in FGF for the many cases with <3 l/minute. These results show that departments choosing to use inexpensive automatic email feedback on FGF should target all anaesthetists and focus on variation in FGF among anaesthetists’ cases.