bluuebunny/crossref_metadata_2025_split huggingface dataset:
Bispectral Index Guided Timing of Intubation without Neuromuscular Blockade during Sevoflurane Induction of Anaesthesia in Adults
Authors: Van Twest R. M. 
Published: January 2019

The aim of this study was to assess the effectiveness of bispectral index monitoring (BIS) as a guide to the timing of intubation during sevoflurane induction of anaesthesia without the use of neuromuscular blocking agents in adults, and specifically, whether a target BIS value of 25 provides better intubating conditions than a target BIS of 40. Forty patients were randomized into one of two groups, a target BIS 25 (n=21) or a target BIS 40 (n =19). Patients received premedication with midazolam 20 μg/kg and fentanyl 0.5 μg/kg. Sevoflurane induction of anaesthesia was initiated and titrated to reach the target BIS value and maintained within the target range for two minutes. The trachea was then intubated, with intubating conditions being assessed using a standardized scale. The BIS 25 group had a superior median intubating score of 4 (range 3–9, [IQR 4–5]) vs the BIS 40 group with a median of 7 (5–10, [6–9], P<0.001). The time to reach target BIS values was not statistically different (BIS 25 group 6.6 min, BIS 40 group 5.1 min, P=0.054). End-tidal sevoflurane concentration upon reaching the target BIS was higher in the BIS 25 group (5.3%±1.2%) vs the BIS 40 group (3.5% ±0.95) (P<0.001). There was no statistical difference in haemodynamic parameters between groups. A target BIS value of 25 provides good to excellent intubating conditions and better intubating conditions than a target BIS of 40 during sevoflurane induction of anaesthesia without the use of neuromuscular blocking agents.
Critical Incidents in a Multidisciplinary Intensive Care Unit
Authors: Chacko J. , Raju H. R. , Singh M. K. , Mishra R. C. 
Published: January 2019

We aimed to determine the type and frequency of critical incidents in a multidisciplinary intensive care unit, to determine outcomes consequent to these incidents and to devise corrective strategies. Prospectively collected data on critical incidents during a 33-month period were analysed. In all, 1918 patients were admitted to the unit during the study period. Each incident was analysed in detail. A system-based corrective strategy was sought for and implemented as appropriate. In these patients, 280 critical incidents were reported during the study period, resulting in 3.4 incidents per 100 patient days. Airway-related incidents were the most frequent (32.8%) followed by line-related (21.8%) and drug-related (15%) incidents. Thirty-two incidents (11.4%) led to adverse outcomes. There were four deaths that occurred as a direct consequence of or contributed to by the incident, all due to airway-related incidents. A major physiological change occurred in 3.6% of incidents, while 6.4% of incidents resulted in a minor physiological change. Critical incidents were common in our multidisciplinary ICU, although adverse outcomes were rare.
After-Hours Discharge from Intensive Care Increases the Risk of Readmission and Death
Authors: Pilcher D. V. , Duke G. J. , George C. , Bailey M. J. , Hart G. 
Published: January 2019

Despite reports showing night discharge from an intensive care unit (ICU) is associated with increased mortality, it is unknown if this has resulted in changes in practice in recent years. Our aim was to determine prevalence, trends and effect on patient outcome of discharge timing from ICU throughout Australia and New Zealand. Two datasets from the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD) were examined: 1. All submissions to the APD from 1.1.2003 to 31.12.2004 to determine contemporary practices. 2. Forty hospitals which had submitted continuous data between 1.1.2000 and 31.12.2004 to determine trends in practice over time. Outcomes investigated were hospital mortality and ICU readmission rate. Between 1.1.2003 and 31.12.2004, the ANZICS APD reported 76,690 patients discharged alive from ICU; 13,968 (18.2%) were discharged after-hours (between 1800 and 0559 hours). After-hours discharges had a higher readmission rate (6.3% vs. 5.1%; P= <0.0001) and higher mortality (8.0% vs. 5.3%; P= <0.0001). Peak readmission (8.6%) and mortality rates (9.7%) were seen in patients discharged between 0300 and 0400 hours. After-hours discharge was a predictor of mortality (odds ratio 1.42, 95% confidence interval 1.32-1.52; P= <0.0001) in multivariate analysis. Between 2000 and 2004, after-hours discharges increased (P=0.0015) with seasonal peaks during winter. The risk of death increased as the proportion of patients discharged after-hours rose. After-hours discharge from ICU is associated with increased risk of death and readmission to ICU. It has become more frequent. The risk of death increases as more after-hours discharges occur.
Prospective Audit Comparing Intrathecal Analgesia (Incorporating Midazolam) with Epidural and Intravenous Analgesia after Major Open Abdominal Surgery
Authors: Duncan M. A. , Savage J. , Tucker A. P. 
Published: January 2019

Potentiation of opioid analgesia can be achieved by the addition of midazolam intrathecally. At our institution, analgesia following open abdominal surgery is provided by continuous infusion of analgesic solutions either intravenously, intrathecally (incorporating midazolam) or epidurally. We report the results of a study comparing outcomes with these three analgesic regimens following major open abdominal surgery. This was an unblinded prospective audit of pain service intervention rates, pain scores and other outcomes after intravenous, intrathecal and epidural analgesia after open abdominal surgery in patients over 60 years of age. Both elective and emergency cases were included over a nine-month period. Patients ventilated for 24 hours or more were excluded. The analgesic regimens were as follows: 1. Intravenous: patient controlled analgesia with morphine + ketamine infusion 0.1 to 0.2 mg/kg/h. 2. Intrathecal: (morphine 10 μg/ml+midazolam 100 μg/ml + bupivacaine 0.05%) commenced at 2 ml/h. 3. Epidural: bupivacaine 0.125% + fentanyl 2 μg/ml at 6 to 14 ml/h. Co-analgesic administration was as per our usual practice but was not standardised. The median number of calls per patient to the pain service differed between the intravenous (1), intrathecal (1) and epidural (3) groups. The number of unintentional analgesic regimen terminations differed between the intravenous (1), intrathecal (1) and epidural (5) groups. Pain scores differed significantly between groups and were lowest in the intrathecal group at all time points. The findings indicate that the intrathecal group had both a low requirement for postoperative interventions/ resources and excellent analgesia. It appears to be a suitable alternative to the other techniques.
A Comparison of Tape-Tyingc versus a Tube-Holding Device for Securing Endotracheal Tubes in Adults
Authors: Murdoch E. , Holdgate A. 
Published: January 2019

During the transfer of intubated patients, endotracheal tube security is paramount. This study aims to compare two methods of securing an endotracheal tube in adults: tying with a cloth tape versus the Thomas Endotracheal Tube Holder (Laerdal). A manikin-based study was performed using paramedics and critical care doctors (consultants and senior trainees) as participants. Each participant was asked to secure an endotracheal tube that had been placed within the trachea of a manikin a total of six times, the first three times using tied cloth tape and the last three times using a Thomas Endotracheal Tube Holder. Following each 'fixation' and after the participant had left the room, the security of the tube was tested by applying a fixed force laterally and to the right by dropping a 1.25 kg weight a distance of 50 cm. The amount of movement of the tube with respect to the teeth was measured and recorded in millimetres. Two-hundred-and-seventy tube fixations (135 tied vs. 135 tube holder) were performed by 45 participants. The degree of tube movement was significantly higher when the tube was secured with a tie compared with when the tube holder was used (median movement 22 mm vs. 4 mm, P <0.0001). We have demonstrated that the tube holder device minimised tube movement in a manikin model when compared with conventional tape tying. The use of this device when transporting intubated patients may reduce the risk of tube displacement though further clinical studies are warranted.
Immediate Management of Inadvertent Dural Puncture during Insertion of a Labour Epidural: A Survey of Australian Obstetric Anaesthetists
Authors: Newman M. J. , Cyna A. M. 
Published: January 2019

Immediate management of inadvertent dural puncture during insertion of an epidural needle during labour is controversial and evidence to guide clinical practice is limited. We surveyed Australian obstetric anaesthetists by anonymous postal questionnaire. Of the 671 surveys sent, 417 (62%) were returned. Following dural puncture, 265 respondents (64%) indicated that they “would usually remove the Tuohy needle and resite”. The most common reason for this decision was concern regarding the safety of intrathecal catheters (ITC) (n=236, 89%), in particular, the risk of misuse (n=182, 70%). The most frequently reported reason for “usually inserting an ITC” was that this reduced the incidence (n=120, 84%) and severity (n=110, 77%) of post dural puncture headache. Increased frequency of ITC insertion was reported by respondents who practised more frequent sessions of obstetric anaesthesia, had fewer years of experience as a consultant anaesthetist and worked in a public hospital. The more widespread use of ITCs seems to be limited by safety concerns.
The Role of Extra Corporeal Membrane Oxygenation for Treatment of the Adult Respiratory Distress Syndrome: Review and Quantitative Analysis
Authors: Chalwin R. P. , Moran J. L. , Graham P. L. 
Published: January 2019

The role of Extra corporeal membrane oxygenation (ECMO) has not been formally validated for patients with adult respiratory distress syndrome. In anticipation of publication of the conventional ventilation versus ECMO in severe adult respiratory failure (CESAR) trial, the role of ECMO in this setting was reviewed. An electronic search for studies reporting the use of ECMO for the treatment of adult respiratory distress syndrome revealed two randomised controlled trials and three non-controlled trials. Bayesian analysis on the two randomised controlled trials produced an odds ratio mortality of 1.28 (credible interval 0.24 to 6.55) demonstrating no significant harm or benefit. Pooling was not possible for the non-controlled studies because of differing admission status and ECMO selection criteria and an inability to control for these differences in the absence of individual patient data. A large number (n=35) of case series have been published with generally more positive results. We also present a comprehensive narrative commentary on the history, current practice and future for ECMO. ECMO, as rescue therapy for adult respiratory distress syndrome, appears to be an unvalidated rescue treatment option. Analysis and review of trial data does not support its application; however the body of reported cases suggests otherwise. Until the CESAR trial provides an authoritative answer ECMO will continue to be offered on a case by case basis.
An Audit of Analgesia Requirements for High-Dose-Rate Prostate Brachytherapy
Authors: Doyle C. A. , Loadsman J. A. , Hruby G. 
Published: January 2019

We audited the analgesic, anti-emetic and anti-spasmodic drug usage of patients undergoing high-dose-rate brachytherapy for prostate cancer at the Royal Prince Alfred Hospital. With institutional ethics committee approval, we retrospectively reviewed the records of the first 45 patients undergoing high-dose-rate prostate brachytherapy from January 2003 to July 2005. We collected data regarding the dose of intra- and postoperative analgesics and the anti-emetic and anti-spasmodic drugs administered for the duration of the patients’ hospital stay. We converted oral oxycodone doses to parenteral morphine equivalents for the purposes of this study, dividing the oxycodone dose by three. The median age of the patients was 69 (range 55 to 80) years. All had general anaesthesia for the catheter insertion procedure. Twenty-five patients (56%) received intraoperative morphine from 5 to 12 mg (mean 9 mg). Forty-three patients (96%) received regular postoperative paracetamol (1 g qid). Thirty-six patients (80%) required additional postoperative opioid administration with an overall mean (all 45 patients included) of 14.5 mg of parenteral morphine equivalents over the entire postoperative course. Thirty-nine patients received intraoperative hyoscine butylbromide to reduce bladder spasm. Fourteen patients were administered antiemetics. These findings indicate that analgesic requirements during the period in which the prostate brachytherapy catheters remained in place were minimal in most cases. Simple analgesic regimens (regular oral paracetamol, antispasmodics as required for bladder spasm and oral/subcutaneous opioids as required) appear to have been adequate for our patients.
Abdominal Compartment Syndrome Complicating Paediatric Extracorporeal Life Support: Diagnostic and Therapeutic Challenges
Authors: Lam M. C. W. , Yang P. T. , Skippen P. W. , Kissoon N. , Skarsgard E. D. 
Published: January 2019

We report three paediatric cases, and summarise the reported experience in two others, with cardiorespiratory failure requiring extracorporeal life support for which supportive pump flows could not be maintained due to abdominal compartment syndrome. In two of our patients, the mechanism of abdominal compartment syndrome was massive intra-abdominal fluid extravasation secondary to sepsis, while in the third, the mechanism was post-traumatic intra-abdominal haemorrhage. Although all three children eventually died, decompressive laparotomy and arrest of haemorrhage in the trauma patient restored venous return and enabled technically adequate extracorporeal life support. In two previously reported cases of sepsis with massive fluid resuscitation resulting in abdominal compartment syndrome, one patient died without attempted decompression, while the other patient survived after peritoneal catheter placement restored venous return. Once correctable causes of inadequate venous cannula drainage have been excluded, abdominal compartment syndrome should be considered in any patient on extracorporeal life support with a taut abdomen and reduced venous return. If abdominal compartment syndrome can be proven or is strongly suspected, there may be a role for selective decompressive laparotomy.
Acid-Base Effects of a Bicarbonate-Balanced Priming Fluid during Cardiopulmonary Bypass: Comparison with Plasma-Lyte 148. A Randomised Single-Blinded Study
Authors: Morgan T. J. , Power G , Venkatesh B. , Jones M. A. 
Published: January 2019

Fluid-induced metabolic acidosis can be harmful and can complicate cardiopulmonary bypass. In an attempt to prevent this disturbance, we designed a bicarbonate-based crystalloid circuit prime balanced on physico-chemical principles with a strong ion difference of 24 mEq/l and compared its acid-base effects with those of Plasma-Lyte 148, a multiple electrolyte replacement solution containing acetate plus gluconate totalling 50 mEq/l. Twenty patients with normal acid-base status undergoing elective cardiac surgery were randomised 1:1 to a 2 litre prime of either bicarbonate-balanced fluid or Plasma-Lyte 148. With the trial fluid, metabolic acid-base status was normal following bypass initiation (standard base excess 0.1 (1.3) mEq/l, mean, SD), whereas Plasma-Lyte 148 produced a slight metabolic acidosis (standard base excess -2.2 (2.1) mEq/l). Estimated group difference after baseline adjustment was 3.6 mEq/l (95% confidence interval 2.1 to 5.1 mEq/l, P=0.0001). By late bypass, mean standard base excess in both groups was normal (0.8 (2.2) mEq/l vs. -0.8 (1.3) mEq/l, P=0.5). Strong ion gap values were unaltered with the trial fluid, but with Plasma-Lyte 148 increased significantly on bypass initiation (15.2 (2.5) mEq/l vs. 2.5 (1.5) mEq/l, P <0.0001), remaining elevated in late bypass (8.4 (3.4) mEq/l vs. 5.8 (2.4) mEq/l, P <0.05). We conclude that a bicarbonate-based crystalloid with a strong ion difference of 24 mEq/l is balanced for cardiopulmonary bypass in patients with normal acid-base status, whereas Plasma-Lyte 148 triggers a surge of unmeasured anions, persisting throughout bypass. These are likely to be gluconate and/or acetate. Whether surges of exogenous anions during bypass can be harmful requires further study.
Decreased Cytosolic Glucocorticoid Receptor Levels in Critically Ill Patients
Authors: Siebig S. , Meinel A. , Rogler G. , Klebl F. , Wrede C. E. , Gelbmann C. , Froh S. , Rockmann F. , Bruennler T. , Schoelmerich J. , Langgartner J. 
Published: January 2019

The immune system and the hypothalamic-pituitary-adrenal axis are linked by several mechanisms. Intracellular glucocorticoid receptors represent one important connection. The aim of this study was to examine the coherence between the number of glucocorticoid receptors, activation of the hypothalamic-pituitary-adrenal axis, inflammatory cytokine levels and the severity of illness in critically ill patients. In a prospective study, blood was collected from 20 healthy members of the hospital staff (control group) and 50 ventilated patients (sample group) within the first 24 hours after intubation and within three days of extubation. 5H-dexamethasone-binding assay was used to assess cytoplasmatic free glucocorticoid receptors levels. ACTH, cortisol, IL-6 and TNFα. levels were measured by ELISA. In the sample group, specific binding of 5H-dexamethasone was significantly decreased compared to the control group. Glucocorticoid receptor levels tended to be lower in more severely ill patients. Plasma cortisol and ACTH levels were significantly different from the control group after extubation but not at intubation. Severe illness is associated with rapid down-regulation of 5H-dexamethasone binding. This decrease occurs before elevation of plasma cortisol. Therefore, down-regulation of cortisol binding may be directly associated with the stress response and not due to feedback regulation following increase in plasma cortisol levels.
A Randomised Comparison of Parecoxib Versus Placebo for Pain Management following Minor Day Stay Gynaecological Surgery
Authors: Luscombe K. S. , McDonnell N. J. , Muchatuta N. A. , Paech M. J. , Nathan E. A. 
Published: January 2019

At therapeutic concentrations, parecoxib selectively inhibits the cyclo-oxygenase-2 enzyme. We investigated the impact of a single preoperative dose of parecoxib on pain relief following minor gynaecological surgery. Ninety women undergoing uterine dilatation and curettage, with or without hysteroscopy, were randomised to receive either 40 mg of parecoxib intravenously or a saline placebo prior to induction of standardised general anaesthesia. Exclusion criteria included a preoperative history of renal dysfunction or hypertension and the pre-operative use of anti-inflammatory or opioid medication. The primary endpoint was the pain score during recovery. There was no difference in global pain scores or area under the curve for pain scores in the recovery area. Pain scores with coughing one hour after surgery were low in both groups but significantly lower after parecoxib (median 2 [interquartile range 0 to 4] parecoxib group vs 2 [interquartile range 0 to 6] placebo group, P=0.037). The 24 hour Quality of Recovery score did not differ significantly between groups but the parecoxib group was less likely to experience headache at 24 hours postoperatively (12 vs 38%, P=0.007) and reported complete satisfaction more frequently (78 vs 57%, P=0.042). The preoperative administration of parecoxib was associated with a significant but small decrease in dynamic pain scores one hour postoperatively. Women who received preoperative parecoxib had a lower incidence of postoperative headache and higher satisfaction.
Remifentail Infusion for Paediatric Bronchoscopic Foreign Body Removal: Comparison of Sevoflurane with Propofol for Anaesthesia Supplementation for Bronchoscope Insertion
Authors: Zhang J. , Wang Y. , Li B. , Zhang W. 
Published: January 2019

The study compared sevoflurane or propofol as anaesthesia supplements to remifentanil infusion and topical local anaesthesia for insertion of a rigid bronchoscope for bronchial foreign body removal in children aged one to three years. Seventy children were randomly allocated to two groups to receive remifentanil infusion at 0.2 μg.kg-1.min-1 with either sevoflurane or propofol supplements for insertion of the rigid bronchoscope. Heart rate and systolic blood pressure before anaesthesia, prior to and on insertion of the bronchoscope and one, three, five, seven and ten minutes after insertion were measured. Incidence of cough and apnoea were recorded. The haemodynamic changes during bronchoscopy were moderate and did not differ between groups. The sevoflurane group had a lower incidence of cough than the propofol group. No significant difference was detected in the incidence of apnoea between groups. It can be concluded that remifentanil infusion with modest use of general anaesthetic agents facilitates rigid bronchoscopy successfully in children.
Audit of Initial use of the Ultrasound-Guided Transversus Abdominis Plane Block in Children
Authors: Palmer G. M. , Luk V. H. Y. , Smith K. R. , Prentice E. K. 
Published: January 2019

The extent of dermatomal block post transversus abdominis plane block is described in adults as T7-L1; other authors argue extent above T10 is infrequent (supra-iliac 20 ml injection). A paediatric guideline recommends this block for upper and lower abdominal surgery using 0.2 ml/kg. We aimed (through prospective audit) to document the multi-level block achieved with ultrasound-guided transversus abdominis plane block in children having abdominal surgery, during a departmental training period. Data included patient, anaesthetic and surgical details, transversus abdominis plane block characteristics (anterior supra-iliac injections) and dermatomal blockade to ice. Twenty-seven children received 38 blocks performed by 58% consultant and 42% trainee operators (90% novices): 16 unilateral/11 bilateral for umbilical (1), inguinal (13), laparoscopic (8) and laparotomy (5) surgery. Dermatomal assessment for 35 blocks (mean local anaesthetic volume 0.4 ml/kg [SD 0.2]) revealed the median blockade achieved was 3 dermatomes (interquartile range 3 to 4) involving T10 to L1 in 75% of patients. Eight blocks (six patients) also involved T8 and T9, following 0.31 to 0.81 ml/kg. One patient (3% of assessed blocks) had no block to ice at 60 minutes, but required no postoperative analgesia. Ultrasound-guided transversus abdominis plane blocks performed by supra-iliac approach and novice operators produced lower abdominal sensory blockade in children of usually 3 to 4 dermatomes, and should be offered for lower abdominal surgery only, as only 25% had upper abdominal block extension. The optimal local anaesthetic dose/volume, duration of effect and utility for these blocks in relation to peripheral and neuraxial blockade needs clarification.