bluuebunny/crossref_metadata_2025_split huggingface dataset:
Problems with Ventilation: An Analysis of 2000 Incident Reports
Authors: Russell W. J. , Webb R. K. , Van Der Walt J. H. , Runciman W. B. 
Published: January 2019

A review of the first 2000 incidents reported to the Australian Incident Monitoring Study found 317 incidents which involved problems with ventilation. The major portion (47%) were disconnections; 61% of these were detected by a monitor. Monitor detection was by a low circuit pressure alarm in 37% but this alarm failed to warn of non-ventilation in 12 incidents (in 6 because it was not switched “on” and in 6 because of a failure to detect the disconnection). Failure of detection was usually with ventilator bellows descending in expiration. Complete failure to ventilate occurred in 143 incidents, most commonly because of a disconnection. Disconnection was associated, in one-third of the cases, with interference to the anaesthetic circuit by a third party and in nearly half with surgery on the head and neck. Leaks affected ventilation in 129 incidents, but in only 19 was ventilation totally lost; leaks associated with seal failure of the absorber were common. Misconnections occurred in 36 incidents, most commonly involving the scavenging system. The frequency of a complete failure to check an anaesthetic machine was greater when an induction room was involved than when only the operating theatre was the site of the incident. These incidents suggest that meticulous checking and monitoring for failure of ventilation, preferably using at least two separate, self-activating systems is highly desirable. The Australian and New Zealand College of Anaesthetists’ policy on low circuit pressure alarms, oximetry and capnography is vindicated by these reports.
Recovery Room Incidents in the First 2000 Incident Reports
Authors: Van Der Walt J. H. , Webb R. K. , Osborne G. A. , Morgan C. , Mackay P. 
Published: January 2019

Of the first 2000 incidents reported to the Australian Incident Monitoring Study 120 (6%) occurred in the recovery room after general, regional or local anaesthesia. Over two thirds (69%) of these involved the respiratory system, 19% were cardiovascular, 3 % involved the central nervous system and 9% were miscellaneous in nature. These recovery room incidents were associated with significantly more adverse outcomes (56%) than incidents in the operating theatre (24%). The types and relative frequencies of these recovery room incidents were similar to those of serious recovery complications in a recent analysis of closed malpractice claims; this suggests that incident monitoring may be useful in the study and prevention of recovery room complications. Over three quarters (77%) of all recovery incidents (and 88% of respiratory incidents) were detected clinically; the remainder were first detected by a monitor. A theoretical analysis showed that over 95% of respiratory events, had they been allowed to evolve, would have been detected by pulse oximetry before organ damage occurred, emphasising the potential importance of pulse oximetry in reducing adverse outcome from any complication in the recovery ward which might be “missed” by clinical observation. The findings of this study underline the importance of having an adequate number of trained recovery nursing staff supported by the availability of a pulse oximeter for each patient at least until the return of protective reflexes and the ability to maintain adequate arterial saturation has been established.
System Failure: An Analysis of 2000 Incident Reports
Authors: Runciman W. B. , Webb R. K. , Lee R. , Holland R. 
Published: January 2019

Although 70–80% of problems have some component of human error, its overall contribution to many problems may be small; studies of complex systems have revealed that up to 85% are primarily due to deficiencies in the lay-out and processes of the system. The anaesthetist has to operate in a complex system; many problems originate from deficiencies in this system. Information of relevance to system failure was extracted from the first 2000 incidents reported to the Australian Incident Monitoring Study (AIMS). A system-based deficiency directly contributed to one-quarter of problems (four-fifths if human factors are included), some aspect of the system minimized the adverse outcome in over half of all cases (four-fifths if human factors are included), and in two-thirds (three-quarters if human factors are included) a system-based strategy would have been helpful; the system was implicated in 90% of all incidents (97% if human factors are included). Regardless of whether or not all human error should be regarded as part of the “system”, attempts to modify its incidence and nature have to emanate from the system. AIMS reporting pathways and the organizations involved in developing and implementing strategies to improve the system operate at four levels. Level I involves the use of AIMS reports by hospitals and group practices for audit at a local level. Level II involves AIMS participants sending forms to the AIMS central office; collated information is then sent back to contributors by newsletter. Level III involves interaction between AIMS and the major professional bodies and level IV interaction between AIMS, these bodies and a variety of national and international agencies. Over 100 topics were identified from the AIMS data for consideration at one or more of these levels. AIMS has the potential not only to play a vital practical role in the continued enhancement of the quality of anaesthetic practice, but also to provide a valuable resource for research at the increasingly important interface between human behaviour and complex systems.
Cytokines in Plasma and Ultrafiltrate during Continuous Arteriovenous Haemofiltration
Authors: Tønnesen E. , Hansen M. B. , Höhndorf K. , Diamant M. , Bendtzen K. , Wanscher M. , Toft P. 
Published: January 2019

Cytokines are considered to be important mediators in the pathophysiology of sepsis and septic shock. We investigated if continuous arteriovenous haemofiltration (CAVH) could be used to remove excessive amounts of the cytokines tumour necrosis factor-α (TNFα), interleukin (IL)-1α and IL-6 from peripheral blood in critically ill patients. Nine septic patients with renal failure were treated with CAVH. Ultrafiltrate and plasma were tested for cytokines by ELISA. All patients had detectable TNFα and IL-6 plasma levels, ranging from 10-750 pg/ml and 50-4,575 pg/ml, respectively. TNFα was removed by the ultrafiltrate with concentrations ranging from 10-1,000 pg/ml. The TNFα levels were significantly higher in the ultrafiltrate samples than in the corresponding plasma samples (P <0.003). IL-6 was undetectable in the ultrafiltrate from five of the patients despite concomitant high plasma levels. IL-1α was detectable in both plasma and ultrafiltrate in four patients. All patients developed multi-organ failure and septic shock and seven died. It is concluded that TNFα and IL-1α but not IL-6 can be removed by CAVH in patients with sepsis.
Infusing Liquid Anaesthetics into a Closed Circuit
Authors: Weir H. M. , Kennedy R. R. 
Published: January 2019

Closed circuit anaesthesia offers the user many advantages but practical problems impede its widespread use. When conventional vaporizers are employed adequate amounts of agent cannot be delivered into a totally closed circuit during the early stages of an anaesthetic. Direct injection, or infusion, of liquid anaesthetic into the circuit overcomes this problem. The standard method for injecting agents directly into circuits is that described by Lowe and Ernst1. Their system can be approximated to a series of constant rate infusions, as is frequently done for propofol, and forms the basis of our technique. For anaesthesia without nitrous oxide, liquid isoflurane should initially be infused into the circuit at a rate in ml/hr of 14 + 0.4 × weight in kg. After five minutes the infusion rate is reduced to 20% of this value. These rates are altered in the light of measured concentrations and clinical responses.
Anaesthesia for Laser Prostatectomy
Authors: Costello T. G. , Costello A. J. 
Published: January 2019

A retrospective review was undertaken to examine current anaesthetic practice in a single institution for the management of patients undergoing laser ablation of the prostate for benign prostatic hypertrophy at St Vincent's Private Hospital, Melbourne. Two groups of patients (totalling 72) were identified, one undergoing the surgery with a regional anaesthetic technique and a smaller group on full anticoagulant therapy for associated medical problems where general anaesthesia was preferred.
Postoperative Epidural Fentanyl Infusion—is the Addition of 0.1% Bupivacaine of Benefit?
Authors: Paech M. J. , Westmore M. D. 
Published: January 2019

A randomised, double-blind controlled clinical trial was conducted in 90 women scheduled for major abdominal gynaecological oncology surgery to determine the effect of adding 0.1% plain bupivacaine to a thoracic epidural fentanyl infusion. Following combined epidural and general anaesthesia, patients were randomised to receive epidural fentanyl 10 μg/ml, with (group FB) or without (group F) bupivacaine. After an initial 50 μg bolus of fentanyl, infusion rate was adjusted according to need between 2 and 10 ml/hr for 48 hours. The two groups (n = 40) were similar with regard to age, weight and preoperative status. Analgesia both at rest and with movement were significantly better in group FB (P < 0.0001) during the first 24 hours postoperatively, the greatest difference occurring in the 4 to 16 hour period. There was no significant difference between groups from 24 to 48 hours postoperatively. Fentanyl utilisation was significantly lower in group FB (median 41 versus 53 μg/hr, P <0.001), although clinically the fentanyl dose-sparing effect of bupivacaine was small and did not reduce opioid-induced side-effects. There was no significant difference between groups with respect to side-effects or lower limb weakness, although fewer patients in group FB could be mobilised on the morning of the first postoperative day (P <0.01). Nevertherless, all study patients were ambulant by the same afternoon. We concluded that, in this patient population, the addition of 0.1% bupivacaine to a thoracic epidural fentanyl infusion was beneficial in the early postoperative period.
Patterns of Coagulopathy during Liver Transplantation: Experience with the First 75 Cases using Thrombelastography
Authors: Mcnicol P. L. , Liu G. , Harley I. D. , Mccall P. R. , Przybylowski G. M. , Bowkett J. , Angus P. W. , Hardy K. J. , Jones R. M. 
Published: January 2019

Using both conventional laboratory clotting profile and thrombelastography, coagulation status was monitored intraoperatively during liver transplantation in the first 75 cases performed at the Austin Hospital between June 1988 and October 1992. Superimposed on a baseline coagulopathy due to liver disease is a specific pattern of coagulation disturbance which occurs during a liver transplant. Fibrinolysis occurs in the anhepatic stage, worsens with early reperfusion and then spontaneously resolves. In addition reperfusion is associated with a transient clotting defect. If blood loss is excessive, coagulopathy due to massive transfusion may compound the situation. Thrombelastography is a measurement technique allowing rapid on-site assessment of functional clotting status’. It is particularly useful in liver transplant surgery. In combination with clinical bleeding assessment it facilitates selective use of component therapy (fresh frozen plasma, platelets and cryoprecipitate) and specific drug treatment only when it is appropriate. It also acts as a liver function test, being especially useful in assessing the graft after reperfusion.
Blood Loss and Transfusion Requirements in Liver Transplantation: Experience with the First 75 Cases
Authors: Mcnicol P. L. , Liu G. , Harley I. D. , Mccall P. R. , Przybylowski G. M. , Bowkett J. , Angus P. W. , Hardy K. J. , Jones R. M. 
Published: January 2019

The blood loss data and transfusion requirements including blood bank, salvaged washed red cells, fresh frozen plasma and cryoprecipitate were analysed for the first 75 cases of liver transplantation performed at the Austin Hospital between June 1988 and October 1992. The mean blood loss was 8.8 litres (standard deviation 14.1) with a median value of 4.0 litres. Blood product use expressed as mean number of units (SD) was bank red blood cells 7.1 (12.7), washed red blood cells 3.9 (5.9), fresh frozen plasma 7.1 (9.1), platelets 5.1 (7.4), and cryoprecipitate 1.7 (5.1). These results demonstrate that liver transplantation can be performed without imposing excessive demands on blood transfusion services. Management should include surgical techniques to minimize bleeding and use of autologous transfusion. Use of component therapy (FFP, platelets and cryoprecipitate) should not be empirical. It should be selective on the basis of clinical bleeding assessment and guided by results of the laboratory coagulation profile and changes in thrombelastographic (TEG) parameters.
Is There a Role for Selective Decontamination of the Digestive Tract in Primarily Infected Patients in the ICU?
Authors: Hammond J. M. J. , Potgieter P. D. 
Published: January 2019

The role of selective decontamination of the digestive tract (SDD) for the prevention of nosocomial infection in critically ill patients remains controversial, and the efficacy of this technique in patients who are already infected on presentation to the intensive care unit has not previously been assessed. We performed a double-blind randomized placebo controlled trial of SDD (parenteral cefotaxime, six-hourly oral and enteral polymyxin E, tobramycin, and amphotericin B vs placebo) for all infected patients presenting to the ICU requiring mechanical ventilation for more than 48 hours and ICU stay of more than 5 days. Daily clinical and microbiological monitoring for secondary infection was undertaken until hospital discharge. In all, 59 selective decontamination and 76 placebo fully comparable patients fulfilled criteria for enrolment and analysis (APACHE II 15.2 vs 15.1). The number of patients receiving SDD who developed nosocomial infections was significantly reduced (P = 0.048), and there were no infections caused by the enterobacteriaceae or Candida spp in this group. No difference in ICU (17.5 vs 18.8 days) or hospital stay (32.7 vs 34.2 days) or mortality (17% vs 22.3%) was shown. Critically ill, primarily infected patients are protected from nosocomial infection by the use of SDD.
The Use of “Quality-Adjusted Life Years” (QALYs) to Evaluate Treatment in Intensive Care
Authors: Kerridge R. K. , Glasziou P. P. , Hillman K. M. 
Published: January 2019

This study examines the feasibility of using Quality-Adjusted Life Years (QALYs) to assess patient outcome and the economic justification of treatment in an Intensive Care Unit (ICU). 248 patients were followed for three years after admission. Survival and quality of life for each patient was evaluated. Outcome for each patient was quantified in discounted Quality-Adjusted Life Years (dQALYs). The economic justification of treatment was evaluated by comparing the total and marginal cost per dQALY for this patient group with the published cost per QALY for other medical interventions. 150 patients were alive after three years. Quality of life for most longterm survivors was good. Patient outcome (QALYs) was greatest for asthma and trauma patients, and least for cardiogenic pulmonary oedema. The tentative estimated cost- effectiveness of treatment varied from AUD $297 per QALY for asthma to AUD $2323 per QALY for patients with pulmonary oedema. This compares favourably with many preventative and non-acute medical treatments. Although the methodology is developmental, the measurement of patient outcome using QALYs appears to be feasible in a general hospital ICU.
A Double-Blind Randomized Prospective Study Comparing Ondansetron with Droperidol in the Prevention of Emesis following Strabismus Surgery
Authors: Davis A. , Krige S. , Moyes D. 
Published: January 2019

A prospective double-blind study was conducted to compare the anti-emetic efficacy of ondansetron and droperidol in preventing postoperative emesis following strabismus surgery. A sample size of 213 patients was divided into three equal groups to receive ondansetron 150 μg/kg (Group A), ondansetron 75 μg/kg (Group B), or droperidol 75 fig/kg (Group C). All patients received a standardized anaesthetic technique. All episodes of emesis, recovery time, and time to tolerating oral fluids were recorded. The incidence of emesis during 24 hours was Groups A and B 19.7%, and Group C 28.2%. The lower incidence of emesis recorded by the ondansetron groups compared with the droperidol group was not statistically significant. Ondansetron at 75 μg/kg was as effective as 150 μg/kg in reducing emesis when compared with droperidol. Mean time to discharge from the recovery room was 75.3 minutes (Group A), 44.4 minutes (Group B), and 41.0 minutes (Group C). The mean time to tolerating oral fluids was 356.5 minutes (Group A), 402.8 minutes (Group B), and 378.1 minutes (Group C). There was no statistical difference in discharge times from recovery or time to tolerating oral fluids in any of the three groups.
The Efficacy of Adding a Continuous Intravenous Morphine Infusion to Patient-Controlled Analgesia (PCA) in Abdominal Surgery
Authors: Dawson P. J. , Libreri F. C. , Jones D. J. , Libreri G. , Bjorkstein A. R. , Royse C. F. 
Published: January 2019

The effect of adding a continuous infusion of morphine 1 mg/hr to patient-controlled intravenous analgesia was studied in a randomized double-blind trial. Ninety-six patients scheduled for abdominal surgery were enrolled; 38 received PCA and continuous infusion (PCA + C), 45 received PCA alone and 13 were excluded because of protocol violations. PCA was delivered via an ABBOTT 4200 pump with settings of morphine 1 mg bolus and five-minute lockout in both groups. A separate pump delivered a continuous infusion of morphine 1 mg/ml (PCA + C) or 9% normal saline (PCA) at 1 ml/hr for three postoperative days. Pain was assessed by hourly verbal pain scores (VPS) and daily visual analog pain scores at rest and on movement (VASrest, VASmove). PCA delivered morphine and the demand to delivery ratio (D/D ratio) were used as indirect indicators of pain. These were assessed during daytime (0800–2200 hours), sleep (2200–0500 hours) and on first waking (0500–0800 hours). Patient demographics were similar. Patients receiving a continuous infusion had lower pain scores during the first 24 hours but not thereafter (VPS P=0.04, VASmove P=0.02). The PCA group delivered more PCA morphine during 0500–0800 hours and 0800–2200 hours on the first day only. There was no significant difference in the D/D ratio for any time period during the three days. Total morphine delivery was greater in the PCA + C group on the second and third postoperative days (P= 0.009 and P=0.0001 respectively). The incidence of respiratory depression and the total number of complications were significantly higher in those receiving continuous infusion (P=0.04 and P=0.011 respectively.) Adding a continuous morphine infusion of 1 mg/hr to the described PCA settings for three days following abdominal surgery improved analgesia during the first 24 hours but was associated with a greater incidence of complications.
Clincial Experience with Patient-Controlled and Staff-Administered Intermittent Bolus Epidural Analgesia in Labour
Authors: Paech M. J. , Pavy T. J. G. , Sims C. , Westmore M. D. , Storey J. M. , White C. 
Published: January 2019

A prospective randomized study was Performed to detail clinical experience with both patient-controlled epidural analgesia (PCEA) and midwife-administered intermittent bolus (IB) epidural analgesia during labour, under the conditions pertaining in a busy obstetric delivery unit. Both methods used 0.125% bupivacaine plus fentanyl, and similar rescue supplementation although management decisions related to epidural analgesia were made principally by attending midwives One hundred and ninety-eight women were recruited and data analysed from 167 (PCEA n = 82 IB n=85) The groups were demographically similar. Median hourly pain scores, ratings of analgesia and satisfaction did not differ Maximum pain scores were significantly higher in those receiving IB epidural analgesia (P<0.05). The PCEA group had a significantly higher rate of supplementation and bupivacaine use (P<0.01), and a longer duration of the second stage of labour (P<0.03) The relative risk of instrumental delivery with PCEA versus the IB method was 1.57 (CI 1.07–2.38) Experience within our unit with PCEA is contrasted with that of IB epidural analgesia, the method most commonly used; and with that of controlled trials comparing these two methods.
Accuracy of the Tonometric Function of Recycled Gastric Tonometer Catheters
Authors: Freebairn R. C. , Buckley T. A. , Twyford C. J. , Oh T. E. 
Published: January 2019

We investigated the accuracy of recycled gastric tonometer catheters, using a prospective laboratory model, within the Intensive Care Unit of a University teaching hospital. Ten used tonometer catheters and three new catheters were exposed to known constant PCO2 levels between 23–65 torr (3.06–8.66 kPa) in a gas mixing chamber, at a temperature of 35.5–38°C and a relative humidity >95%. The tonometer balloons were primed with normal saline, and after a 30-minute equilibration time, the saline was sampled for PCO2 measurements. Steady-state PCO2 (PCO2(ss)) and gastric mucosal pH (pHi) values were derived using a correction factor and the Henderson-Hasselbalch equation. There was no difference in the mean or distribution of PCO2(ss) values between recycled and new catheters. The PCO2(ss) values of recycled catheters were within the 95% confidence limits of those of new catheters. Individual catheter values did not differ significantly from each other (ANOVA P=0.05). Using an arterial HCO3- value of 21 mmol/l, the calculated pHi values of used catheters varied <1.5% of the mean pHi of new catheters. The tonometric performance of recycled gastric tonometer catheters was similar to that of new catheters when tested in vitro.
Analgesic Efficacy of Paracetamol in Children Using Tonsillectomy as a Pain Model
Authors: Anderson B. , Kanagasundarum S. , Woollard G. 
Published: January 2019

The analgesic efficacy of paracetamol was assessed in a prospective, randomized, double-blinded study of 100 children undergoing tonsillectomy with or without adenoidectomy. Fifty children were given paracetamol elixir 40 mg/kg 40 minutes preoperatively (Group A); the remaining 50 children were given an oral placebo 40 minutes pre-operatively and paracetamol suppositories 40 mg/kg after induction of anaesthesia (Group B). Paracetamol was the only analgesic given and was given either orally or rectally in order to produce high variations in plasma paracetamol concentrations postoperatively. At 30 minutes after the end of surgery a pain score (0–10) was obtained and a venous blood sample was taken for serum paracetamol concentration analysis. Children given paracetamol elixir had a higher mean paracetamol concentration (0.15 [SD 0.06] mmol/l vs 0.05 [SD 0.03] mmol/l, P < 0.001) and a lower median pain score (5 vs 7, P < 0.02) than those who were given suppositories. The use of rescue morphine was higher (10 vs 23, P < 0.001) in the latter group. The incidence of nausea and vomiting was the same in both groups (20%) during the 24 hour postoperative period. Plasma paracetamol concentrations of 0.066–0.132 mmol/l are known to reduce temperature; plasma paracetamol concentrations which provide analgesia are unknown. Children with plasma paracetamol concentrations above 0.07 mmol/l had superior analgesia to those with concentrations below this level (P < 0.05).