bluuebunny/crossref_metadata_2025_split huggingface dataset:
In Situ Simulation-based Team Training for Post-cardiac Surgical Emergency Chest Reopen in the Intensive Care Unit
Authors: Nunnink L. , Welsh A.-M. , Abbey M. , Buschel C. 
Published: January 2019

Emergency chest reopen of the post cardiac surgical patient in the intensive care unit is a high-stakes but infrequent procedure which requires a high-level team response and a unique skill set. We evaluated the impact on knowledge and confidence of team-based chest reopen training using a patient simulator compared with standard video-based training. We evaluated 49 medical and nursing participants before and after training using a multiple choice questions test and a questionnaire of self-reported confidence in performing or assisting with emergency reopen. Both video- and simulation-based training significantly improved results in objective and subjective domains. Although the post-test scores did not differ between the groups for either the objective (P=0.28) or the subjective measures (P=0.92), the simulation-based training produced a numerically larger improvement in both domains. In a multiple choice question out of 10, participants improved by a mean of 1.9 marks with manikin-based training compared to 0.9 with video training (P=0.03). On a questionnaire out of 20 assessing subjective levels of confidence, scores improved by 3.9 with manikin training compared to 1.2 with video training (P=0.002). Simulation-based training appeared to be at least as effective as video-based training in improving both knowledge and confidence in post cardiac surgical emergency resternotomy.
A Prospective Randomised Controlled Trial of Ultrasound Guided versus Nerve Stimulation Guided Distal Sciatic Nerve Block at the Popliteal Fossa
Authors: van Geffen G. J. , van den Broek E. , Braak G. J. J. , Giele J. L. P. , Gielen M. J. , Scheffer G. J. 
Published: January 2019

The direct visualisation of nerves and adjacent anatomical structures may make ultrasonography the preferred method for nerve localisation. In this prospective randomised study, we investigated whether, for distal sciatic nerve block in the popliteal fossa, an ultrasound guided technique would result in the use of less local anaesthetic without changing block characteristics and quality. Using electrical nerve stimulation or ultrasound guidance, the nevre was identified in two groups of 20 patients scheduled for lower limb surgery. Hereafter lignocaine 1.5% with adrenaline 5 μg/ml was injected. The attending anaesthesiologist assessed the injected volume. Significantly less local anaesthetic was injected in the ultrasound group compared to the nerve stimulation group (17 vs. 37 ml, P <0.001), while the overall success rate was increased (100% vs. 75%; P=0.017). We conclude that the use of ultrasound localisation for distal sciatic nerve block in the popliteal fossa reduces the required dose of local anaesthetic significantly, and is associated with a higher success rate compared to nerve stimulation without changing block characteristics.
Ventilation and Weaning Practices in Australia and New Zealand
Authors: Rose L. , Presneill J. J. , Johnston L. , Nelson S. , Cade J. F. 
Published: January 2019

Using a one-day prospective point prevalence design, this study aimed to characterise the current practice of mechanical ventilation and weaning in Australian and New Zealand intensive care units. During 2005, a bi-national one-day survey of 55 intensive care units found the point-prevalence of mechanical ventilation to be 284/491(58%). Common modes used were synchronised intermittent mandatory ventilation with pressure support, pressure support ventilation (each 116/284, 41%) and pressure-control modes (48/284, 17%). Relative to volume-control modes, pressure-control was more frequently used for patients with respiratory disease (odds ratio 4.7, 95% confidence interval 2.4 to 9.2, P <0.001) or greater severity of illness (odds ratio 1.7, 95% confidence interval 1.1 to 2.6, P=0.01, per five-point increment in the maximum sequential organ failure score). Excluding cardiothoracic surgery patients, the Kaplan-Meier estimated median total ventilation duration was 1.9 days (interquartile range 0.8 to 6.8 days). Apart from 24/255 (9.4%) patients who received only pressure support ventilation, weaning methods (attempted in 255 patients, 29 prior deaths) included: change to pressure support ventilation (186/255, 73%), T-piece (31/255, 12%) or other methods (14/255, 5.5%). The point prevalence of mechanical ventilation was greater than comparable international studies. Australian and New Zealand intensive care unit ventilatory practices are similar, but differ substantially from published international survey results, due to a near absence of assist/control, prominent use of pressure-control modes and a preference for pressure support ventilation weaning as opposed to T-piece.
Application of the Laboratory Risk Indicator in Necrotising Fasciitis (LRINEC) Score to Patients in a Tropical Tertiary Referral Centre
Authors: Holland M. J. 
Published: January 2019

The objective of this study was to assess the applicability and usefulness of the Laboratory Risk Indicator in Necrotising Fasciitis (LRINEC) score in patients from our institution. A retrospective analysis was undertaken of the case notes of all patients admitted to our facility between January 2002 and December 2005 with the admission diagnosis of necrotising fasciitis and the application of the LRINEC score upon the initial blood tests. The sensitivity, specificity and likelihood ratios were then calculated for patients with a LRINEC score of ≥6 compared with the findings of a surgical biopsy. Twenty-eight patients were identified as having the admission diagnosis of necrotising fasciitis on the hospital database and were eligible for the study. Ten of these had biopsy-proven necrotising fasciitis. With a cut-off score of ≥6, the LRINEC score had a sensitivity of 80%, specificity of 67%, a positive predictive value of 57% and a negative predictive value of 86% in distinguishing the patients with proven necrotising fasciitis from those with severe soft tissue infections. The likelihood ratio of a positive biopsy was 2.4 and the likelihood ratio of a negative biopsy was 0.3. A cut-off value of ≥6 of the LRINEC score was not overly sensitive or specific, and the likelihood ratios suggest that, at this cut-off level, the LRINEC score would have only a very small effect on the post-test probability of the patients in the studied population having necrotising fasciitis.
Evidence-based Evolution of the High Stakes Postgraduate Intensive Care Examination in Australia and New Zealand
Authors: Lee R. P. , Venkatesh B. , Morley P. 
Published: January 2019

The fellowship examination for intensive care medicine in Australia and New Zealand, first held in 1979, has undergone four major periods of development and change since inception. These periods are characterised as: 1. 1979 to 1996 – initiation and establishment of the exam as a relevant and comprehensive assessment process for a new specialty. 2. 1997 to 2001 – revision to increase breadth of coverage, increase reliability for a growing number of candidates and ensure that each candidate received the same exam: • Expansion: to incorporate assessment of CanMEDS skills (including communication, procedures and professional qualities). • Lengthening: to increase the number of exposures, to ensure reliability. • Quarantining of candidates: to allow the provision of a similar exam for each candidate. 3. 2002 to 2006 – increasing emphasis on examiner training, standard setting and increasing feedback to candidates to improve the educational experience and guide exam preparation. Blueprinting of questions to maintain validity. 4. 2008 onwards – logistic revision to ensure feasibility for a rapidly growing number of candidates and refinement to apply modem standard setting and quality control The exam has been regarded as a ‘tough but fair’ assessment in its 30 years of existence and the committee overseeing its development has aimed to continually review the process to maintain those qualities as well as reliability, validity and feasibility. The increasing number of candidates has allowed accumulation of usable statistics but has tested the feasibility of running such a labour intensive exam. To date, there have been 800 presentations to the exam with 498 successful candidates.
Pharmacoeconomics of Volatile Inhalational Anaesthetic Agents: An 11-Year Retrospective Analysis
Authors: Weinberg L. , Story D. , Nam J. , McNicol L. 
Published: January 2019

With continuously increasing expenditure on health care resources, various cost containment strategies have been suggested in regard to controlling the cost of inhalational anaesthetic agents. We performed a cost identification analysis assessing inhalational anaesthetic agent expenditure at a tertiary level hospital, along with an evaluation of strategies to contain the cost of these agents. The number of bottles of isoflurane, sevoflurane and desflurane used during the financial years 1997 to 2007 was retrospectively determined and the acquisition costs and cumulative drug expenditure calculated. Pharmacoeconomic modelling using low fresh gas flow anaesthesia was performed to evaluate practical methods of cost reduction. The use of isoflurane decreased from 384 bottles during 1997 to 204 in 2007. In contrast, use of sevoflurane increased from 226 bottles during 1998 to 875 during 2007. Desflurane use increased from 34 bottles per year during 2002 (its year of introduction) to 163 bottles per year in 2007. While the inflation-adjusted cumulative expenditure for these inhalational agents (Australian dollars) increased from $132,000 in 1997 to over $326,000 in 2007, an increase of 168%, patient workload over the same period increased by only 11%. Pharmacoeconomic modelling demonstrated that sevoflurane at 2 l/minute costs 19 times more than isoflurane at 0.5 l/minute. For the financial years 1997 to 2007, we found a progressive shift from the cheaper isoflurane to the more expensive agents, sevoflurane and desflurane, a shift associated with marked increases in costs. Low flow anaesthesia with isoflurane is one strategy to reduce costs.
A Comparison of Two Different Doses of Rectal Ketamine Added to 0.5 mg.kg-1 Midazolam and 0.02 mg.kg-1 Atropine in Infants and Young Children
Authors: Wang X. , Zhou Z. J. , Zhang X. F. , Zheng S. 
Published: January 2019

In some circumstances, a high degree of sedation that results in a child being unconscious at the time of parental separation is desirable. We set out to investigate the efficacy and safety of a rectal premedication regimen designed to produce this increased level of sedation. Sixty-seven children aged two to 24 months were randomised into two groups. Group MK received 4 mg.kg-1 ketamine, 0.5 mg.kg-1 midazolam and 0.02 mg.kg-1 atropine and group MKK received 8 mg.kg-1 ketamine, 0.5 mg.kg-1 midazolam and 0.02 mg.kg-1 atropine per rectum. The sedation score at the time of parental separation 30 minutes after drug administration and the response to intravenous cannulation were evaluated on a four-point scale. Respiratory rate, heart rate and arterial oxygen saturation were recorded immediately before parental separation. More patients in group MKK were asleep during separation (62 vs 35%, P <0.05). Fewer patients in group MKK cried during intravenous cannulation (37 vs 68%, P <0.05). Sedation scores were significantly increased at both time points. There was no difference between groups in vital signs at the time of parental separation and no adverse respiratory events occurred during the study period. In cases where a high degree of sedation following premedication in infants and toddlers is desired, the addition of 8 mg.kg-1 ketamine to 0.5 mg.kg-1 midazolam and 0.02 mg.kg-1 atropine administered rectally is more efficacious than 4 mg.kg-1 ketamine.
The Provision of Anaesthesia for Children by Non-Subspecialist Anaesthetists: Expectations of Newly Qualified Consultant Anaesthetists and their Prospective Employers in Victoria
Authors: Castanelli D. J. , Stevenson K. , Monagle J. P. 
Published: January 2019

We surveyed newly qualified consultant anaesthetists and their prospective employers in Victoria, regarding their expectations for the provision of paediatric anaesthesia by anaesthetists who have not completed subspecialty training in paediatric anaesthesia (generally-trained anaesthetists). Responses were received from 15 of 19 (79%) eligible Directors and 26 of 37 (70%) newly qualified Australian and New Zealand College of Anaesthetists (ANZCA) Fellows. Of those responding, 80% of Directors and 82% of Fellows would expect a generally-trained anaesthetist to anaesthetise children two years of age or older. Regional Directors expected generally-trained anaesthetists to anaesthetise younger children than metropolitan Directors, and Directors’ expectations were not influenced by their own practice. Testing these age limits with a series of simple case descriptions showed there is recognition from both Directors and Fellows that the stated age limits would be modified in both directions by case complexity and comorbidities. The new consultants who responded were significantly less confident than Directors in their ability to resuscitate and stabilise a critically ill child prior to transfer if required. Only 50% agreed they still met all the requirements of the ANZCA paediatric module and only 37.5% had the level of confidence they achieved during their paediatric rotations. We suggest that current training provides capacity to routinely anaesthetise well children two years of age or older. However, it appears more training would be required for most anaesthetists undertaking anaesthesia for younger patients or more complex paediatric cases. This raises the question of subspecialty endorsements within ANZCA Fellowship.
What are we Telling Our Patients? A Survey of Risk Disclosure for Anaesthesia in Australia and New Zealand
Authors: Braun A. R. , Leslie K. , Merry A. F. , Story D. 
Published: January 2019

The aim of our study was to determine the range of risks disclosed in four commonly-encountered clinical scenarios: knee arthroscopy, lumbar laminectomy, laparoscopic appendicectomy and laparotomy, and then to determine how often five commonly-disclosed risks were disclosed for each scenario. We conducted a pilot survey of consultant anaesthetists in the Auckland City Hospital, the Royal Melbourne Hospital and the Austin Hospital (response rate 59%). A web survey was then sent to 500 randomly-selected Australian and New Zealand College of Anaesthetists Fellows (response rate 29%). In the pilot survey, a wide range of risks were disclosed: five (range 0 to 13) for knee arthroscopy, seven (0 to 16) for lumbar laminectomy, six (0 to 13) for appendicectomy and nine (0 to 24) for laparotomy. In the web survey, the disclosure rates for all risks varied widely from “rarely” to “always”. Respondents were more likely to disclose risks infrequently if they were male (odds ratio 5.7, P=0.002) or exclusively in private practice (odds ratio 4.1, P=0.02). Age >45 years was not associated with disclosure frequency (odds ratio 1.65, P=0.23). While the low response rate limits the validity and generalisability of many of our findings, we can nevertheless confidently conclude that risk disclosure varies widely in Australia and New Zealand. This large variation should be of concern to all anaesthetists. More work is needed to understand the reasons for this variation, and to develop a stronger consensus among anaesthetists about what risks should be disclosed.
Anaesthesia for Robotic Gynaecological Surgery
Authors: Gupta K. , Mehta Y. , Jolly A. Sarin , Khanna S. 
Published: January 2019

Robotic surgery is gaining widespread popularity due to advantages such as reduced blood loss, reduced postoperative pain, shorter hospital stay and better visualisation of fine structures. Robots are being used in urological, cardiac, thoracic, orthopaedic, gynaecological and general surgery. Robotic surgery received US Food and Drug Administration approval for use in gynaecological surgery in 2005. The various gynaecological robotic operations being performed are myomectomy, total and supracervical hysterectomy, ovarian cystectomy, sacral colpopexy, tubal reanastomosis, lymph node dissection, surgery of retroperitoneal ectopic pregnancy, Moskowitz procedure and endometriosis surgery. The anaesthetic considerations include difficult access to the patient intraoperatively, steep Trendelenburg position, long surgical duration and the impact of pneumoperitoneum. We highlight the complications encountered in these surgeries and methods to prevent these complications. Robotic gynaecological surgery can be safely performed after considering the physiological effects of the steep Trendelenburg position and of pneumoperitoneum. The benefits of the surgical procedure should be weighed against the risks in patients with underlying cardiorespiratory problems.
Cerebrospinal Fluid Volume and Nerve Root Vulnerability during Lumbar Puncture or Spinal Anaesthesia at Different Vertebral Levels
Authors: Prats-Galino A. , Reina M. A. , Puigdellívol-Sánchez A. , Juanes Méndez J. A. , De Andrés J. A. , Collier C. B. 
Published: January 2019

Cerebrospinal fluid (CSF) and nerve root volumes within the lumbosacral dural sac were estimated at various vertebral levels, in an attempt to determine any possible relevance to the incidence of nerve root trauma during lumbar puncture or spinal anaesthesia. Magnetic resonance images from seven patients were studied. Volumes were calculated by semi-automatic threshold segmentation combined with manual editing of each slice. The mean dural sac volume from S1 to T12 was 42.8±5.8 ml and the mean CSF volume 34.3±5.1 ml with the mean root volume being 10.4±2.2 cm3. The mean CSF volume per vertebral segment ranged from 4.3±0.7 ml at L5, to 5.8±2.5 ml at L1, with high inter-individual variability. The mean root volume ranged from 0.6±0.1 cm3 at L5 to 2.4±0.5 cm3 at T12. The conus medullaris was located at L1 in four of the five patients scanned at upper lumbar levels, and at the lower border of L2 in the other. Vulnerability to nerve root damage was expressed as the Vulnerability Index (%), being defined as the ratio of root volume to dural sac volume (CSF volume + root volume). The value ranged between 7 and 14% at L5, increasing rostrally to 30 to 43% at T12. Caution is obviously required in high punctures to avoid contact with the conus medullaris, but the cauda equina is also vulnerable to contact with more caudal punctures and had a Vulnerability Index of about 25% at L4, that increased rostrally.
The Impact of Clinical Protocols in the Management of Severe Sepsis: A Prospective Cohort Study
Authors: Phua J. , Ho B. C. , Tee A. , Chan K. P. , Johan A. , Loo S. , Soh C. R. , Chia N. , Tan A. Y. , Tham H. M. , Chan Y. H. , Koh Y. 
Published: January 2019

This study aimed to assess the availability of clinical protocols and their effect on compliance to the Surviving Sepsis Campaign bundles and on mortality in severe sepsis in ten Singaporean adult teaching intensive care units (ICU). The presence of 11 protocols in the ICUs, steps taken based on the Johns Hopkins University Quality and Safety Research Group's model to translate protocols into practice, and organisational characteristics were assessed. Clinical and research personnel recorded characteristics of patients with severe sepsis who were admitted in July 2009, the achievement of sepsis bundle targets and outcomes. Hospital mortality was 39% for 128 patients. Fewer than half of the ICUs had protocols for early goal-directed therapy, blood cultures, antibiotics, steroids, lung-protective ventilation and weaning. Compliance rates with the resuscitation and management bundles were 18 and 3% respectively. Units with protocols were generally not more likely to achieve associated bundle targets. Steps from the Johns Hopkins model to measure performance, engage teams and sustain and extend interventions were taken in fewer than half of the available protocols. However, on logistic regression analysis, the number of protocols available per ICU was independently and inversely associated with mortality. In conclusion, clinical protocols are infrequently available in Singapore's ICUs and when present do not generally improve compliance to the sepsis bundles. These protocols may, however, be a surrogate marker of the quality of care as they are independently associated with decreased mortality. The use of an integrated and multifaceted approach to translate protocols into practice should be considered.
Cost Analysis of Real-Time Polymerase Chain Reaction Microbiological Diagnosis in Patients with Septic Shock
Authors: Alvarez J. , Mar J. , Varela-Ledo E. , Garea M. , Matinez-Lamas L. , Rodriguez J. , Regueiro B. 
Published: January 2019

Antibiotic treatment for septic shock is generally prescribed on an empirical basis using broad-spectrum antibiotics. Molecular diagnostic techniques can detect the presence of microbial DNA in blood within a few hours and facilitate early, targeted treatment. The aim of this study was to evaluate the economic impact of a real-time polymerase chain reaction technique, LightCycler SeptiFast (LSC), in patients with sepsis. A cost-minimisation study was carried out in patients admitted with a diagnosis of severe sepsis or septic shock to the intensive care unit of a university hospital. The stay in the intensive care unit, hospital admission, 28-day and six-month mortality, and the economic cost of the clinical process were also evaluated. The study involved 48 patients in the LSC group and 54 patients in the control group. The total cost was €42,198 in the control group versus €32,228 in the LCS group with statistically significant differences (P <0.05), giving rise to an average net saving of €9970 per patient. The mortality rate was similar in both groups. The main finding of this study was the significant economic saving afforded by the use of the LCS technique, due to the shortening of intensive care unit stay and the use of fewer antibiotics.