bluuebunny/crossref_metadata_2025_split huggingface dataset:
Strategies in the clinical diagnosis and surgical treatment of OSAHS with multilevel obstruction
Authors: Peng Ben-Gang , Lai You-Qing , Lei Hui-Jia , Zhang Ning , Wang Xin 
Published: January 2019

Objective To examine the safety and effectiveness of individualized treatment strategies that include three principles (security, top-down and priority) for patients with obstructive sleep apnoea hypopnea syndrome (OSAHS) and multilevel obstruction who decline therapy with continuous positive airway pressure (CPAP). Methods Patients with OSAHS and upper airway obstruction who were diagnosed with multilevel obstruction were included in this retrospective study. Patients were evaluated for the degree of obstruction in each level. Three principles were followed in planning the appropriate intervention level and measures to reduce perioperative risks. Polysomnography indices and Epworth sleepiness scores were used to evaluate the efficacy of surgery and improvement in patients’ sleepiness at ≥3 months post-surgery. Results Among 51 patients with OSAHS and multilevel obstruction, three were treated with CPAP, 41 were treated with nasopharyngeal surgery, and seven were treated with oropharyngeal surgery. No severe complications were reported. Following surgery, apnoea hypopnea index and Epworth sleepiness scores were significantly reduced, and the lowest oxygen saturation level was significantly increased. Conclusion The three-principle strategy was safe and effective in planning surgical treatments for patients with OSAHS and multilevel obstruction.
Tenoxicam IV for Major Gynaecological Surgery—Effects on Renal Function
Authors: Jones R. D. M. , Endre Z. , Miles W. , Prankerd R. , Chilvers M. , Willgoss D. 
Published: January 2019

Thirty women presenting for major gynaecological oncology surgery under a standardized, combined epidural/general anaesthetic technique received either placebo or tenoxicam 20 mg intravenously, in a randomized double-blinded manner prior to surgery. Plasma and urinary electrolytes, creatinine, prostaglandins PgE 2 and PgF1α, and thromboxane (T x B 2 ) were collected 12 hours preoperatively and then for four days postoperatively. There were no significant differences in any of the measured parameters between the groups, at any of the measurement times. Mean (SD) creatinine clearance at baseline, 24h and 48h was 100.4 (29.7) and 86.9 (27.5), 128.1 (45.9) and 115.0 (40.3), 137.5 (50.7) and 121.6 (38.6) in the placebo and tenoxicam groups respectively (P=0.28). Both groups required similar amounts of intraoperative ephedrine and intravenous fluids to maintain blood pressure. The minimal changes in plasma and renal parameters reflect predictable responses to major surgery and rehydration rather than any response to cyclooxygenase inhibition. This may underscore the importance of maintenance of blood pressure during the course of surgery and postoperative care, and perhaps the usefulness of a fluid loading regimen to preserve renal function during surgery. The predicted attenuation of renal prostaglandin-mediated protective mechanisms and enhancement of the catecholamine-mediated renal vasoconstriction by the use of a single 20 mg dose of tenoxicam in this study were not seen. Modulation of renal concentrating mechanisms or excretion of sodium and potassium by tenoxicam was not apparent and a large increase in study size would be required to detect a significant difference in these parameters as a consequence of the drug, over and above any changes in response to surgery and epidural anaesthesia.
Complementary Medicine in Intensive Care: Ethical and Legal Perspectives
Authors: Young R. J. , Worswick D. , Stoffell B. 
Published: January 2019

Complementary medicine continues to increase in popularity in the general community. As a result it is likely that requests for the administration of complementary medicine to intensive care patients will be more frequent in the future. It is therefore prudent for intensive care clinicians to address this issue and develop an approach that is consistent. Complementary medicine has not been subjected to well conducted trials to determine its efficacy and risks. Consequently decisions about its use cannot be based on risk/benefit analyses and genuine informed consent cannot be achieved. Therefore complementary medicine should not be incorporated into intensive care practice. Strict adherence to a policy of negating requests for administration of complementary medicine in intensive care patients may result in significant conflicts between intensive care clinicians, patients and families. On occasions the patient or family may insist on the use of complementary medicine and it may be seen as important to their psychological wellbeing to accede to the request. The intensive care clinician is still legally responsible for any treatment administered to the patient, even if it is against medical advice. Nevertheless if there is no demonstrable risk to the patient, complementary medicine can be administered following appropriate counselling and documentation. This review addresses the legal and ethical difficulties that may arise and an approach that may be followed when requests are made for complementary medicine in intensive care patients.
Do Anaesthetized Patients Recover Better after Bispectral Index Monitoring?
Authors: Burrow B. , McKenzie B. , Case C. 
Published: January 2019

Could Bispectral Index (BIS) monitoring during anaesthesia improve the recovery characteristics of patients? Previous studies have shown conflicting results. To eliminate bias, a control group of 75 cases anaesthetized by the authors was compared to a reference group of 141 cases anaesthetized by other anaesthetists. A study group of 71 cases was then anaesthetized by the authors titrating to BIS 40–50 and this was compared with the control group. Recovery characteristics were assessed using a Modified Aldrete score. BIS monitored cases had improvements in blood pressure stability (P=0.023) and respiratory score (P=0.016) throughout the study period. Activity and consciousness levels were higher on arrival in PACU in the BIS monitored group (P=0.015 and P=0.017) but were not maintained. There was no significant difference in mean oxygen saturation scores. The improved recovery characteristics in BIS monitored patients may have positive implications for safety, nursing workload, staffing, and cost savings in the PACU.
PCA Ketamine and Morphine after Abdominal Hysterectomy
Authors: Burstal R. , Danjoux G. , Hayes C. , Lantry G. 
Published: January 2019

Following a standardized general anaesthetic for total abdominal hysterectomy, patients received either patient controlled analgesia (PCA) with morphine 1 mg/ml (group M, n=33) or morphine 1 mg/ml plus ketamine 2 mg/ml (group K, n=37) for 48 hours in a randomized, double-blind fashion. In 43 women the area of allodynia around the scar was mapped as a measure of the degree of central sensitization. A significant reduction in the area of allodynia was found in those receiving ketamine with morphine (42 cm 2 [interquartile range (IQR) 57] compared with 57 cm 2 [IQR 82] z=–2.0, P=0.04) in those receiving morphine alone. There were no significant differences between the two groups with respect to age, or weight, or between the subgroups within which the area of allodynia was measured with respect to length of incision. No significant differences were found between the groups with respect to pain scores, total or hourly drug consumption, patient satisfaction, nausea scores or antiemetic use. Patients in group K were more likely to require PCA for a shorter period than those in group M (median 40 hours, IQR 26 versus 48 hours IQR 7). Ten patients in group K were withdrawn because of side-effects (dysphoria n=4, nausea n=2, pruritus n=4) compared with one in group M (nausea n=1)(P=0.006). The potential usefulness of ketamine after hysterectomy was offset by a high incidence of adverse effects and a lack of opioid-sparing effects, such that combined intravenous ketamine and morphine PCA as used in this study cannot be recommended for routine care.
The Efficacy and Cost-effectiveness of Prophylactic 5-hydroxytryptamine3 Receptor Antagonists: Tropisetron, Ondansetron and Dolasetron
Authors: Paech M. J. , Rucklidge M. W. M. , Banks S. L. , Gurrin L. C. , Orlikowski C. E. P. , Pavy T. J. G. 
Published: January 2019

There are currently three 5-hydroxytryptamine 3 (5-HT 3 ) receptor antagonists available in Australia. In this randomized, double-blind, parallel group study the prophylactic antiemetic effect of a single dose of tropisetron 2 mg, ondansetron 4 mg or dolasetron 12.5 mg was compared after major gynaecological surgery. One hundred and eighteen patients (group T n=42; group O n=36; group D n=40) were evaluated for nausea, vomiting, recovery characteristics and satisfaction for 24 hours postoperatively. A cost-effectiveness analysis was performed. Rescue antiemetic, prochlorperazine 12.5 mg IM, was given if vomiting occurred more than 10 minutes after arrival in the recovery room. If prochlorperazine was ineffective one hour after administration, droperidol 1 mg IV was given. There were no significant differences between groups for the incidence of vomiting during consecutive epochs until 24 hours postoperatively or overall (57%, 75% and 72.5% for groups T, O and D respectively, P=0.18). The incidence and number of rescue antiemetic treatments for nausea or vomiting were similar. The incidence of nausea and the overall and interval nausea scores were similar except for lower “worst nausea” score in group T between 12 and 18 hours (P=0.02). Recovery times, satisfaction and cost per patient did not differ between groups. We conclude that the risk of postoperative nausea and vomiting remained high in this setting despite 5-HT 3 receptor antagonist prophylaxis and that the choice between these agents should be based on the lowest available acquisition cost.
Dimensions of Double-Lumen Tracheobronchial Tubes
Authors: Russell W. J. , Strong T. S. 
Published: January 2019

The diameter of the left main bronchus is the determining dimension when selecting the size of a left tracheobronchial (double-lumen) tube for lung separation. However, this information is not given by any manufacturer, either on the tube or in the package insert. This paper describes the lengths and diameters of the deflated bronchial cuff segment of left tracheobronchial tubes in common use. One hundred and seventy-one left tracheobronchial tubes ranging in size from 28 to 41 nominal French gauge from four manufacturers were measured. There was wide variation between tubes of the same nominal size from the same manufacturer. For tubes of the same size from the same manufacturer, the diameter of the segment with the deflated bronchial cuff varied by more than 1 mm in diameter in some instances.The diameter of the bronchial cuff segment did not consistently decrease as the nominal size decreased even for the same manufacturer. There was major overlap in diameters of the bronchial segments between Fr 41, Fr 39, and Fr 37 tubes from most manufacturers, so that some of the Fr 39 tubes have a bronchial cuff segment diameter as much as 0.5 mm larger than the Fr 41 tube. It is concluded that the current French gauge markings on left tracheobronchial tubes are of very limited value in determining the appropriate size to be selected for a patient. More accurate and consistent dimensions of tracheobronchial tubes are required to improve clinical selection.
Legal Aspects of Withdrawal of Therapy
Authors: Young R. J. , King A. 
Published: January 2019

The ability of intensive care to replace or support vital organ function has resulted in some patients surviving for long periods of time without improvement or a terminal event. In patients with no realistic chance of survival, decisions to withdraw or withhold life-sustaining therapies are commonly made. Withdrawal of life support at the patient's request is lawful at common law and, in some states of Australia, by legal statute. In the intensive care setting though, it is more common for therapy to be withdrawn because the therapy is of no perceived benefit or not in the patient's best interests. However, in Australia there is little case law and very little legislation to direct the decision of whether to withdraw life-sustaining therapy on the grounds of futility or the patient's best interests. The legislation that does exist in Australia, as well as law from other jurisdictions, largely places responsibility for the decision to withdraw therapy on the doctor in charge of the patient's care. However much weight is frequently placed on the wishes of the family. Disagreements between family and clinicians over decisions to withdraw therapy are unusual and generally resolve over time. However if disagreement persists, it may be advisable to apply to the courts for a declaratory judgement, given the tenuous legal basis of withdrawal of life-sustaining therapy in Australia and the uncertainty over the courts’ view of the role of the patient's family in the decision-making process.
Modelling Thirty-day Mortality in the Acute Respiratory Distress Syndrome (ARDS) in an Adult ICU
Authors: Moran J. L. , Solomon P. J. , Fox V , Salagaras M. , Williams P. J. , Quinlan K. , Bersten A. D. 
Published: January 2019

Variables predicting thirty-day outcome from Acute Respiratory Distress Syndrome (ARDS) were analysed using Cox regression structured for time-varying covariates. Over a three-year period, 1996–1998, consecutive patients with ARDS (bilateral chest X-ray opacities, PaO2/FiO2 ratio of <200 and an acute precipitating event) were identified using a prospective computerized data base in a university teaching hospital ICU. The cohort, 106 mechanically ventilated patients, was of mean (SD) age 63.5 (15.5) years and 37% were female. Primary lung injury occurred in 45% and 24% were postoperative. ICU-admission day APACHE II score was 25 (8); ARDS onset time from ICU admission was 1 day (median: range 0-16) and 30 day mortality was 41% (95% CI: 33%-51%). At ARDS onset, PaO2/FiO2 ratio was 92 (31), 81% had four-quadrant chest X-ray opacification and lung injury score was 2.75 (0.45). Average mechanical ventilator tidal volume was 10.3 ml/ predicted kg weight. Cox model mortality predictors (hazard ratio, 95% CI) were: APACHE II score, 1.15 (1.09-1.21); ARDS lag time (days), 0.72 (0.58-0.89); direct versus indirect injury, 2.89 (1.45-5.76); PaO2/FiO2 ratio, 0.98 (0.97-0.99); operative versus non-operative category, 0.24 (0.09-0.63). Time-varying effects were evident for PaO2/FiO2 ratio, operative versus non-operative category and ventilator tidal volume assessed as a categorical predictor with a cut-point of 8 ml/kg predicted weight (mean tidal volumes, 7.1 (1.9) vs 10.7 (1.6) ml/kg predicted weight). Thirty-day survival was improved for patients ventilated with lower tidal volumes. Survival predictors in ARDS were multifactorial and related to patient-injury-time interaction and level of mechanical ventilator tidal volume.
The Differential Flow of Epidural Local Anaesthetic via Needle or Catheter: A Prospective Randomized Double-blind Study
Authors: Yun M. J. , Kim Y. C. , Lim Y. J. , Choi G. H. , Ha M. , Lee J. Y. , Ham B. M. 
Published: January 2019

The extent of epidural anaesthesia and pattern of spread of contrast medium, using different injection techniques, has not been well documented. Therefore, in this prospective, randomized, double-blind study, the extent of anaesthesia and pattern of spread of contrast medium following an epidural bolus injection, via either a Tuohy needle or an epidural catheter, were compared. The study had two parts. In the first, 59 of 79 patients scheduled for a lower extremity operation under epidural anaesthesia were randomly allocated to one of the two groups. Anaesthesia was achieved with an epidural injection of 10 to 15 ml (including a 3 ml test dose) of 0.75% ropivacaine and fentanyl 25 μg via either a Tuohy needle (Group N, n=31) or a catheter (Group C, n=28). The level of sensory anaesthesia was recorded. In the second part, the remaining 20 patients were randomized to initially receive 5 ml of contrast medium via either a Tuohy needle (Group NE, n=10) or a catheter (Group CE, n=10). The extent of spread was recorded radiologically. Unilateral or missed blocks and additional dose requirement were absent in Groups N and C. No differences were found in the extent of sensory anaesthesia or the spread of contrast medium. Twenty per cent of catheter tips lay outside the lateral margins of the vertebral bodies. We found that an epidural bolus injection, via either a Tuohy needle or a catheter, made no difference in regard to spread of local anaesthetic or contrast medium in the epidural space.
Small Simulators for Teaching Procedural Skills in a Difficult Airway Algorithm
Authors: Parry K. , Owen H. 
Published: January 2019

Difficulty with intubation, ventilation or both is a significant issue for anaesthetists. The American Society of Anesthesiologists’ Guidelines for the Management of the Difficult Airway is an algorithm widely used when airway difficulties are encountered. Ideally, anaesthetic trainees should have access to simulators suitable for learning and practising how to manage airway difficulties, but most models have been designed primarily for resuscitation training. The aim of this study was to determine which small airway simulators could be used to practise steps in the Difficult Airway Algorithm (DAA). We identified the essential elements of the DAA relating to endotracheal intubation (laryngoscope, Trachlight and Fastrach), external laryngeal manipulation, dedicated airway devices (LMA, Combitube) and trans-tracheal ventilation using the Enk oxygen flow modulator (Cook). Each element was studied in adult airway models sold for airway management training. The DAA elements were studied in 16 different airway models. No single model achieved our criteria of “good/very realistic” for all elements. All elements of the DAA could be used in the Difficult Airway Trainer Deluxe (MPL) and Bill (VBM/Mallinckrodt) but it would be necessary to acquire at least two trainers to achieve “good/very realistic” in all techniques studied. Anaesthetic departments planning to acquire small simulators for airway management training should undertake a training-needs analysis and apply this to the performance characteristics of the simulators. Generally, at least two airway training models will be needed to teach all steps of the DAA effectively.
The Use of the Novel Calcium Sensitizer Levosimendan in Critically Ill Patients
Authors: Plöchl W. , Rajek A. 
Published: January 2019

Levosimendan, a novel calcium sensitizer, enhances cardiac contractility by increasing myocyte sensitivity to calcium, and induces vasodilation. In this prospective observational study the haemodynamic effects of levosimendan in postoperative critically ill patients are reported. Twelve patients with the need for inotropic support were studied. One dose of levosimendan (12.5 mg) was administered at a rate of 0.1-0.2 μg.kg−1.min−1, either alone or in addition to pre-existing inotropic therapy. Haemodynamic measurements were obtained at baseline, and at 3 h, 6 h, 12 h, and 24 h after the start of the levosimendan infusion. Levosimendan significantly increased cardiac output from (mean±SD) 4.3±0.9 l.min−1 to 5.2±1.5 l.min−1 after 24 h (P=0.013), by increases in stroke volume (baseline 47±15 ml, after 24 h 57±25 ml, P=0.05), as heart rate remained unchanged. Systemic vascular resistance decreased from 1239±430 dyn.sec.cm−5 at baseline to 963± 322 dyn.sec.cm−5 at 24 h (P<0.001). Pre-existing inotropic therapy present in ten patients remained unchanged or was reduced. In postoperative critically ill patients, infusion of levosimendan exerted favourable haemodynamic responses. Levosimendan increased cardiac output by increasing stroke volume, which might be attributed primarily to its inotropic properties. Due to its cyclic adenosine monophosphate independent positive inotropic effects, levosimendan may be of value as adjunctive therapy to other inotropic drugs in critically ill patients.
Entropy and Bispectral Index during Anaesthesia in Children
Authors: Davidson A. J. , Kim M. J. , Sangolt G. K. 
Published: January 2019

Entropy™ is a new EEG based technology developed as a measure of depth of anaesthesia. The Entropy algorithm quantifies the degree of disorder in the EEG. During anaesthesia the disorder of the EEG, or entropy, falls. Entropy is independent of absolute frequency or amplitude of the EEG. This may make it suitable for paediatric anaesthesia. In this prospective observational blinded study we recorded the Entropy and Bispectral Index™ in 23 children undergoing general anaesthesia with isoflurane and nitrous oxide, supplemented with peripheral nerve blockade. We recorded Entropy at several times during anaesthesia, pre-awakening and 1-minute post-awakening. Entropy pre-awakening and 1 minute after awakening was compared to a value during anaesthesia in three age groups; less than one-year-old (infants), one to five years (toddlers) and five to twelve years (children). The correlation between BIS and Entropy was also calculated. Entropy post-awakening was higher than during anaesthesia for all age groups. Entropy pre-awakening was higher than during anaesthesia for the children and toddlers. This was not as apparent in infants. There was a strong correlation between BIS and Entropy for children and toddlers. The correlation was less for infants. This study demonstrates that, in children, Entropy is lower during anaesthesia when compared to awake values. Further evaluation in the paediatric population is worthwhile.
Reliability of Fingertip Skin-surface Temperature and its Related Thermal Measures as Indices of Peripheral Perfusion in the Clinical Setting of the Operating Theatre
Authors: Akata T. , Kanna T. , Yoshino J. , Higashi M. , Fukui K. , Takahashi S. 
Published: January 2019

During the perioperative period, evaluation of digital blood flow would be useful in early detection of decreased circulating volume, thermoregulatory responses or anaphylactoid reactions, and assessment of the effects of vasoactive agents. This study was designed to assess the reliability of fingertip temperature, core-fingertip temperature gradients and fingertip-forearm temperature gradients as indices of fingertip blood flow in the clinical setting of the operating theatre. In 22 adult patients undergoing abdominal surgery with general anaesthesia, fingertip skin-surface temperature, forearm skin-surface temperature, and nasopharyngeal temperature were measured every five minutes during the surgery. Fingertip skin-surface blood flow was simultaneously estimated using laser Doppler flowmetry. These measurements were made in the same upper limb with an IV catheter (+IV group, n=11) or without an IV catheter (-IV group, n=11). Fingertip blood flow, transformed to a logarithmic scale, significantly correlated with any of the three thermal measures in both the groups. Their rank order as an index of fingertip blood flow in the -IV group was forearm-fingertip temperature gradient (r=-0.86) > fingertip temperature (r=0.83) > nasopharyngeal-fingertip temperature gradient (r=-0.82), while that in the +IV group was nasopharyngeal-fingertip temperature gradient (r=-0.77) > fingertip temperature (r=0.71) > forearm-fingertip temperature gradient (r=-0.66). The relation of fingertip blood flow to each thermal measure in the -IV group was stronger (P<0.05) than that in the +IV group. In the clinical setting of the operating theatre, using the upper limb without IV catheters, fingertip skin-surface temperature, nasopharyngeal-fingertip temperature gradients, and forearm-fingertip temperature gradients are almost equally reliable measures of fingertip skin-surface blood flow.