bluuebunny/crossref_metadata_2025_split huggingface dataset:
C-Reactive Protein as a Predictor of Mortality in Critically Ill Patients: A Meta-Analysis and Systematic Review
Authors: Zhang Z. , Ni H. 
Published: January 2019

C-reactive protein is a marker of inflammatory response and has been widely investigated in cardiovascular and infectious diseases, especially to monitor therapeutic success. However, its role as a predictor of clinical outcome in critically ill patients remains uncertain and controversial. The objective of this study was to investigate the predictive value of C-reactive protein in critically ill patients. The databases of PubMed, the Cochrane clinical trial database and EMBASE (from inception to August 2010) were searched. Prospective non-randomised clinical studies comparing C-reactive protein concentrations between survivors and non-survivors were included. Pooled mean difference in C-reactive protein concentrations between survivors and non-survivors was calculated. Heterogeneity was analysed by I2. Sensitivity and subgroup analyses were conducted to explore the heterogeneity. Fourteen studies containing a total of 1969 patients were finally included in our analysis. The weighted mean difference in the C-reactive protein levels between survivors and non-survivors was 9.15 mg/l (95% confidence interval -6.50 to 24.81). The heterogeneity was large with I2=92%. Subsequent investigation of the heterogeneity with sensitivity analyses yielded no significant differences. The subgroup analysis showed that the weighted mean difference in early (within 48 hours) C-reactive protein levels between survivors and non-survivors was not significantly different, in contrast to the late (beyond 48 hours) C-reactive protein level. This was significantly greater in non-survivors with a weighted mean difference of 63.80 mg/l (95% confidence interval 35.67 to 91.93). Our systematic review shows that while the early C-reactive protein concentration is not a good predictor of survival in critically ill patients, the late C-reactive protein concentration may help to identify patients who are at risk of death.
Cerebrospinal Fluid Cytology in Patients Undergoing Combined Spinal Epidural versus Spinal Anaesthesia without an Introducer
Authors: Sharma B. , Gupta S. , Jain N. , Handoo A. , Sood J. 
Published: January 2019

The problem of tissue coring exists despite the availability of smaller gauge spinal needles with special tip designs. The aim of the study was to test the hypotheses that a) subarachnoid block given as a part of a combined spinal epidural intervention by needle-through-needle technique introduces a lesser number of epithelial cells into the subarachnoid space compared to isolated subarachnoid block, and b) after lumbar puncture, the initial few drops of cerebrospinal fluid from the spinal needle will have a higher number of epithelial cells than the subsequent sample. One hundred and seven patients of American Society of Anesthesiologists physical status I to III undergoing infra-umbilical surgery were enrolled. Seven patients were excluded from the study and the rest divided into two groups to receive either combined spinal epidural anaesthesia (group A) or isolated subarachnoid anaesthesia, unaided by an introducer (group B). The two groups were compared for the presence of epithelial cells in cerebrospinal fluid. The initial four to six drops of cerebrospinal fluid (sample 1) were collected, the next four to six drops discarded and the following four to six drops (sample 2) collected. The incidence of coring was 96% in group A and 88% in group B (P=0.142). The median (interquartile range) number of cells in group A, for samples 1 and 2 was 6 (3 to 12.5) and 6 (3 to 10); and in group B, 3.5 (1 to 10) and 4 (1 to 8) respectively. Significant tissue coring was observed with both techniques. Discarding eight to 12 drops of cerebrospinal fluid did not help in reducing the epithelial cell load.
Prevention of Gastrointestinal Bleeding Due to Stress Ulceration: A Review of Current Literature
Authors: Pilkington K. B. , Wagstaff M. J. D. , Greenwood J. E. 
Published: January 2019

Our objective was to audit our current stress ulcer prophylaxis protocol (routine prescription of ranitidine and early enteral feeding) by identifying whether routine prescription of histamine-2 receptor antagonists or proton pump inhibitors as prophylaxis against stress-related mucosal disease and subsequent upper gastrointestinal bleeding is supported in the literature. We also aimed to ascertain what literature evidence supports the role of early enteral feeding as an adjunctive prophylactic therapy, as well as to search for burn-patient specific evidence, since burn patients are at high risk for developing this condition, with the aim of changing our practice. PubMed and Cochrane databases were searched for relevant articles, yielding seven randomised controlled trials comparing histamine-2 receptor antagonists and proton pump inhibitors in the prevention of upper gastrointestinal bleeding associated with stress-related mucosal disease and three separate meta-analyses. Despite level 1 clinical evidence, no significant difference in efficacy between histamine-2 receptor antagonists and proton pump inhibitor treatment groups was demonstrated. No significant difference was demonstrated in the incidence of nosocomial pneumonia between the two drugs given in this indication. However, enteral feeding was found to be safe and effective in preventing clinically significant upper gastrointestinal bleeding. Patients able to tolerate feeds demonstrated no additional benefit with concomitant pharmacological prophylactic therapy. Since all burn patients at the Royal Adelaide Hospital are fed from very early in their admission, the literature suggests that we, like our intensive care unit colleagues, should abolish our reliance on pharmacological prophylaxis, the routine prescription of which is not supported by the evidence.
An Observational Study Exploring Amplitude-Integrated Electroencephalogram and Spectral Edge Frequency during Paediatric Anaesthesia
Authors: Mckeever S. , Johnston L. , Davidson A. J. 
Published: January 2019

Processed electroencephalography is used in adults to guide anaesthesia, but the algorithms used may not apply to infants. Knowledge of infants’ electroencephalogram (EEG) responses to anaesthetics is fragmentary. An earlier pilot study suggested amplitude-integrated EEG (aEEG) may be a useful measure of anaesthetic effect. The aim of this study was to determine how aEEG changes between awake and anaesthetised children of varying ages and to compare the response to that seen with Spectral Edge Frequency 90% (SEF90). A prospective observational study of children receiving a general anaesthetic was conducted. Anaesthetic regimen remained at the discretion of the treating anaesthetist. EEG data were collected using the BrainZ ReBrim™ monitor using forehead and biparietal montages. SEF90 and aEEG were compared across age groups, EEG montage and between awake and anaesthetised states. A total of 178 children (aged 24 days to 14 years) were recruited. All aEEGs were greater during anaesthesia compared to when awake and this difference varied with age. Only children older than two years showed lower SEF90 while anaesthetised compared to when awake. SEF90 from children younger than six months was higher during anaesthesia compared to when awake. Analysis of parietal and forehead EEG montages revealed age-related differences. These findings suggest that SEF90 and aEEG can discriminate between awake and anaesthetised states in older children. In younger children aEEG changes are less pronounced and SEF90 either cannot discriminate between states or responds paradoxically. The aEEG may be marginally better than other EEG parameters in measuring anaesthetic depth in children.
Lignocaine Plasma Levels following Topical Gel Application in Laparoscopic and Hysteroscopic Procedures
Authors: Hewitt E. A. , Armstrong G. , Beg N. , Katz S. , Vancaillie T. G. 
Published: January 2019

The study aim was to determine plasma lignocaine concentrations resulting from topical application of a newly formulated, sterile two-pack lignocaine gel in laparoscopic and hysteroscopic procedures. This was an open label single-centre study in which six female patients underwent laparoscopy and six underwent hysteroscopy. One venous blood sample was extracted pre-gel application, followed by 10 samples over a 24 hour period following application. Samples were centrifuged, stored at −20°C and subsequently analysed for lignocaine and its metabolite, monoethyl-glycinexylidide. Application of gel in doses between 2.7 and 5.8 mg/kg of lignocaine resulted in a maximum plasma concentration in any patient of 1520 ng/ml lignocaine and 240 ng/ml monoethyl-glycinexylidide. These maximum concentrations were recorded in a patient undergoing a laparoscopic procedure and patients undergoing hysteroscopic procedures all recorded lower maximum concentrations compared with patients undergoing laparoscopy; the maximum observed concentrations in a patient having a hysteroscopy were 420 ng/ml lignocaine and 56 ng/ml of monoethyl-glycinexylidide. A new sterile two-pack topical lignocaine gel, applied at the end of laparoscopic and hysteroscopic procedures in doses up to 5.84 mg/kg, resulted in plasma lignocaine levels below those known to have the potential to cause central nervous system toxicity.
An Analysis of Computer-Assisted Pre-Screening Prior to Elective Surgery
Authors: Grant C. , Ludbrook G. L. , O'Loughlin E. J. , Corcoran T. B. 
Published: January 2019

In order to assess the potential utility of guided patient self-assessment as an early preoperative triage tool, a computer-assisted questionnaire delivered by a non-clinician via telephone was 1) compared to face-to-face interview and examination by anaesthetists in outpatient clinics and 2) evaluated as a mechanism to stream patients to day of surgery assessment. In total, 514 patients scheduled for elective surgery in two tertiary public hospitals were assessed initially by telephone and then in an outpatient clinic. Both forms of assessment were marked by panels of specialist anaesthetists, who also provided an opinion on which patients would have been suitable to bypass preoperative anaesthetic outpatient assessment based upon information provided by the telephone interview. Overall, the quality of assessment provided by non-clinician telephone interview was comparable to face-to-face interview by anaesthetists, although more complex issues required face-to-face assessment. Panel review considered that 398 patients (60%) would not have required evaluation by an anaesthetist until the day of surgery, thus avoiding the need to separately attend a preoperative outpatient clinic. The sensitivity of telephone interview provided information to correctly classify patients as suitable for day of surgery evaluation was 98% (95% confidence interval 96 to 99%) with a specificity of 97% (95% confidence interval 92 to 98%). This study demonstrates that remote computer-assisted assessment can produce quality patient health information and enable early patient work-up and triage with the potential to reduce costs through more efficient use of resources.
Learning from Defects using a Comprehensive Management System for Incident Reports in Critical Care
Authors: Arabi Y. M. , Owais S. M. Al , Al-Attas K. , Alamry A. , Alzahrani K. , Baig B. , White D. , Deeb A. M. , Al-Dorzi H. D. , Haddad S. , Tamim H. M. , Taher S. 
Published: January 2019

Summary Incident reporting systems are often used without a structured review process, limiting their utility to learn from defects and compromising their impact on improving the healthcare system. The objective of this study is to describe the experience of implementing a Comprehensive Management System (CMS) for incident reports in the ICU. A physician-led multidisciplinary Incident Report Committee was created to review, analyse and manage the department incident reports. New protocols, policies and procedures, and other patient safety interventions were developed as a result. Information was disseminated to staff through multiple avenues. We compared the pre- and post-intervention periods for the impact on the number of incident reports, level of harm, time needed to close reports and reporting individuals. A total of 1719 incidents were studied. ICU-related incident reports increased from 20 to 36 incidents per 1000 patient days ( P=0.01). After implementing the CMS, there was an increase in reporting ‘no harm’ from 14.2 to 28.1 incidents per 1000 patient days ( P <0.001). There was a significant decrease in the time needed to close incident report after implementing the CMS (median of 70 days [Q1–Q3: 26–212] versus 13 days [Q1–Q3: 6–25, P<0.001]). A physician-led multidisciplinary CMS resulted in significant improvement in the output of the incident reporting system. This may be important to enhance the effectiveness of incident reporting systems in highlighting system defects, increasing learning opportunities and improving patient safety.
Microbial Contamination of Three-Way Taps on Arterial Lines
Authors: Widdowson W. M. , Walker L. , Havill J. H. , Sleigh J. W. 
Published: January 2019

Arterial lines with three-way taps are used to measure blood pressure and aspirate blood, and are a potential source of catheter-related sepsis. Swabs were taken daily from 118 three-way taps on 98 arterial lines in a general intensive care unit. Infusion lines were changed weekly but arterial cannulae were not changed routinely. An overall contamination rate of 24.6% was found with the predominant organism being coagulase negative staphylococcus. The three-way taps became increasingly contaminated with time but this was shown to be unrelated to the manipulation rates. Blood culture organisms in those showing contamination of the three-way taps showed no relationship to the bacteria causing the contamination.
Box Hill Hospital Resuscitation Trolley
Authors: Cranswick P. J. , Rodda M. 
Published: January 2019

A resuscitation trolley has been designed to meet the following requirements. Continuous oxygen supply from the trolley for the duration of the emergency; medical suction of similar strength to that of an ICU treatment bay and provision of equipment and drugs in a modular form, which is uniform across the institution, and which allows immediate replacement from stock. These requirements have been fulfilled whilst maintaining a total trolley weight and manoeuvrability similar to that of commercially manufactured trolleys available in Australia.
The Preoperative Management of Phaeochromocytoma
Authors: Russell W. J. , Metcalfe I. R. , Tonkin A. L. , Frewin D. B. 
Published: January 2019

Although the preoperative use of alpha-receptor antagonist drugs is generally accepted for patients with phaeo-chromocytoma, evidence on the most appropriate treatment and its timing is scarce. In this retrospective study, the effectiveness of the preoperative preparation of fourteen patients who required surgical excision of a phaeochromocytoma was examined in the light of their operative stability. A simple score was developed of blood pressure stability by scoring the need for additional antihypertensive agents intraoperatively before, and blood pressure support after, tumour removal. A higher score indicated greater instability. Twelve patients received phenoxybenzamine and their stability was superior to the two patients treated with labetalol and with prazosin. There was no correlation between the duration of treatment with phenoxybenzamine and the operative stability (r=0.18 P=0.55 Spearman). The five patients who were treated with phenoxybenzamine for longer than 10 days did not have better perioperative blood pressure stability than the five patients who had treatment for less than a week. Predictive factors for intra-operative blood pressure stability were also sought. The degree of postural hypotension after treatment with phenoxybenzamine did not predict operative stability (r=-0.31, P=0.33 Spearman). However, the peak total catecholamine level found during surgery correlated quite well with more operative instability (r=0.65, P=0.031, Spearman), suggesting that patients with phaeochromocytomas with high production of catecholamines are more likely to show cardiovascular instability.
Potential Intrathecal Leakage of Solutions Injected into the Epidural Space following Combined Spinal Epidural Anaesthesia
Authors: Vartis A. , Collier C. B. , Gatt S. P. 
Published: January 2019

A combined spinal epidural anaesthetic (CSE), by design, produces a deliberate multicompartment block across a breached dural membrane. Since the lateral holes of the epidural catheter may lie in close proximity to the dural puncture site, a bolus solution of drug injected via the epidural catheter has the potential to leak through the dural puncture into the subarachnoid space. The aim of this study was to determine the incidence of intrathecal leak by performing an epidurogram. Fifteen patients undergoing surgery with a CSE anaesthetic using a 16 gauge Tuohy/26 gauge pencil point needle were studied. Within three hours of catheter insertion, 12 ml of contrast (iohexol 300 mg/ml) was injected via the epidural catheter under fluoroscopic control with screen recording and exposure of lateral and anteroposterior X-ray plates. All films were later reviewed for evidence of intrathecal spread. We did not observe any evidence of intrathecal spread of contrast. However, caution should be observed during administration of an intraoperative bolus dose of analgesic agent via a catheter inserted as part of a combined spinal epidural anaesthetic technique, particularly with the use of hydrophilic opiods.
Brown Snakes (Pseudonaja Genus): Venom Yields, Prothrombin Activator Neutralization and Implications Affecting Antivenom Usage
Authors: Masci P. P. , Mirtschin P. J. , Nias T. N. , Turnbull R. K. , Kuchel T. R. , Whitaker A. N. 
Published: January 2019

The recent high prevalence of fatal bites by Brown snakes (Pseudonaja genus) has led to this study of venom yields from 66 brown snake milkings over 15 months. The amount of venom obtained from all species was higher than reported previously. Electrophoretic and Western blotting analyses of their venoms showed significantly lower avidity of Brown snake antivenom (BS-AV) for the prothrombin activator (PA) component (190 kD) than for other venom components, including the neurotoxins. The LD50 of P. inframacula has been determined for the first time. SDS-PAGE (sodium dodecyl sulphate-polyacrylamide gel electrophoresis) and Western blotting studies have shown that the Pseudonaja venoms contained proportionately more PA component than venoms of the Taipan (Oxyuranus scutellatus) or the Fierce snake (O. microlepidotus). Neutralization of the prothrombin activator of the Common Brown snake (P. textilis) (Pt-PA) by BS-AV was found to be time dependent and 40% remained unneutralized after 30 minutes incubation. Adult rats administered quantities of Pt-PA (IV) died with acute disseminated intravascular coagulation. Rats were made resistant to Pt-PA by preheparinization or by induction of tolerance to increasing quantities of Pt-PA. There is no evidence that Pt-PA has intrinsic toxicity apart from being a procoagulant. The improvement of BS-AV by addressing its deficiencies should be canvassed.
A Comparison of 0.5% Ropivacaine and 0.5% Bupivacaine for Axillary Brachial Plexus Anaesthesia
Authors: McGlade D. P. , Kalpokas M. V. , Mooney P. H. , Chamley D. , Mark A. H. , Torda T. A. 
Published: January 2019

The purpose of this study was to compare the use of 0.5% ropivacaine with 0.5% bupivacaine for axillary brachial plexus anaesthesia. Sixty-six patients undergoing upper limb surgery were enrolled in a double-blind, randomized, multicentre trial. Five patients were subsequently excluded for various reasons. Of the remaining patients, 30 received 40 ml of 0.5%) ropivacaine and 31 received 40 ml of 0.5% bupivacaine. Brachial plexus block was performed by the axillary approach using a standardized technique with a peripheral nerve stimulator. Parameters investigated included the frequency, onset and duration of sensory and motor block, the quality of anaesthesia and the occurrence of any adverse events. The six principal nerves of the brachial plexus were studied individually. The frequency for achieving anaesthesia per nerve ranged from 70 to 90% in the ropivacaine group and 81 to 87% in the bupivacaine group. The median onset time for anaesthesia was 10 to 20 minutes with ropivacaine and 10 to 30 minutes with bupivacaine, and the median duration was 5.3 to 8.7h with ropivacaine and 6.9 to 20.3h with bupivacaine. Motor block was evaluated at the elbow, wrist and hand, and was completely achieved at a rate of 60 to 73% in the ropivacaine group and 55 to 71% in the bupivacaine group. The median duration of motor block was 6.5 to 7.5h with ropivacaine and 6.0 to 9.0h with bupivacaine. These parameters were not statistically different. The duration of partial motor block at the wrist (6.8 v 16.4h) and hand (6.7 v 12.3h) was significantly longer with bupivacaine. Ropivacaine 0.5% and bupivacaine 0.5%) appeared equally efficacious as long-acting local anaesthetics for axillary brachial plexus block.
Patient-Controlled Epidural versus Intravenous Pethidine to Supplement Epidural Bupivacaine after Abdominal Aortic Surgery
Authors: Blake D. W. , Stainsby G. V. , Bjorksten A. R. , Dawson P. J. 
Published: January 2019

In a double-blind, randomized, crossover study of 25 patients after abdominal aortic surgery, we compared patient-controlled analgesia (PCA) with epidural versus intravenous pethidine. All patients received continuous epidural infusions of 0.125% bupivacaine adjusted to maintain appropriate sensory levels. The 48 hour study period commenced 36 to 48 hours after surgery and covered postoperative days 2 and 3. There was a crossover in PCA mode (epidural or intravenous) after 24 hours. Plasma pethidine concentration at the end of each 24 hour period and the total 24 hour pethidine dose did not change significantly between postoperative days 2 and 3. Pethidine plasma concentration was lower after 24 hours epidural than after intravenous PCA [125 (SD 108) ng/ml versus 171 (SD 107) ng/ml, P=0.03], although pethidine dose did not differ significantly [mean 147 (SD 124) mg/24h]. Visual analog pain scores (VAS) did not differ significantly between postoperative days 2 and 3, or at rest between epidural and IV groups. However, VAS with coughing and with abdominal palpation were lower in the epidural PCA group (P=0.05, 0.008). With a background epidural infusion of 0.125% bupivacaine, PCA with epidural pethidine provided better pain control than PCA intravenous pethidine and this was achieved at lower plasma pethidine concentrations.
Carbon Dioxide Embolism following Diagnostic Hysteroscopy
Authors: Sherlock S. , Shearer W. A. J. , Buist M. , Rasiah R. , Edwards A. 
Published: January 2019

A 50-year-old woman ASA 2 underwent carbon dioxide hysteroscopy under general anaesthesia. Monitoring showed a sudden and rapid fall in end-tidal carbon dioxide followed by oxygen desaturation. She became pulseless and cyanosed. Resuscitation with oxygen, intravenous adrenaline and head-down tilt restored her to haemodynamic stability. Hyperbaric therapy was also administered as air embolism could not be excluded.