| | Title | Date | |
| | Cover Note | | |
| Isoflurane
C. Ball, RN. Westhorpe
| 01/08/2007 |  |
| | Editorial | | |
| After-hours discharge from intensive care: impact on outcome
J. Santamaria
| 01/08/2007 | |
| | Original Paper | | |
 | After-hours discharge from intensive care increases the risk of readmission and death
DV. Pilcher, GJ. Duke, C. George, MJ. Bailey, G. Hart
SUMMARY: 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. | 01/08/2007 | |
| Examining the occurrence of adverse events within 72 hours of discharge from the intensive care unit
N. McLaughlin, GD. Leslie, TA. Williams, GJ. Dobb
SUMMARY: Adverse events have negative consequences for patients, including increased risk of death or permanent disability. Reports describe suboptimal patient care on hospital wards and reasons for readmission to the intensive care unit (ICU) but limited data exists on the occurrence of adverse events, their characteristics and outcomes in patients recently discharged from the ICU to the ward. This prospective observational study describes the incidence and outcomes of adverse events within 72 hours of discharge from an Australian ICU over 12 weeks in 2006. Patients were excluded if they were admitted to ICU after booked surgery or uncomplicated drug overdose, were discharged from ICU to the high dependency unit or had a ‘do-not-resuscitate’ order. Clinical antecedents and preventability were determined for each event. Seventeen (10%) of the 167 discharges that met the inclusion criteria were associated with an adverse event, with nine (52%) judged as probably preventable. Seven adverse events occurred from discharges between 1700 and 0700 hours and seven were on weekends. The most common adverse events were related to fluid management (47%). Outcomes included three ICU readmissions, two high dependency unit admissions and two required one-to-one ward nursing. Two adverse events resulted in temporary disability, seven resulted in prolonged hospital stays and two were associtaed with death. Delay in taking action for abnormal physiological signs and infrequent charting were evident. Whilst the adverse event rate compared favourably with other reports, 64% of the events were considered preventable. A review of support systems and processes is recommended to better target transition from the ICU. | 01/08/2007 | |
| The effects of acidosis and hypothermia on blood transfusion requirements following factor VII administration
K. Hall, P. Forrest, C. Sawyer
SUMMARY: While there is laboratory evidence that the activity of recombinant activated factor VII (rFVIIa) is reduced by the presence of acidosis and hypothermia, there is limited clinical data to support this observation. Recombinant FVIIa may be used as rescue therapy in surgical patients who have bleeding that is refractory to conventional therapy. However, these patients are also frequently acidotic and hypothermic at the time the drug is administered. In this retrospective study, the records of 38 adult surgical patients who received rFVIIa intraoperatively or within six hours postoperatively were reviewed. The requirements for red cell transfusion in the two hours following the administration of rFVIIa and the need for repeated doses of rFVIIa were recorded. The relationship between red cell transfusion and pH and temperature of the patient at the time of rFVIIa administration was assessed by multiple regression analysis.
The major finding was an inverse relationship between the degree of acidosis at the time of rFVIIa administration and the requirement for either subsequent blood transfusion or repeat dosing of rFVIIa (P=0.003 and P <0.001 respectively). For patients with a pH <7.2 vs. pH ≥7.2, the odds ratio for receiving two or more packs of red blood cells within two hours of rFVIIa administration was 15:1. This effect was not observed for hypothermia.
The implication of this study is that rFVIIa may be less effective when administered to severely acidotic patients. Further studies are required to examine whether this is related to the acidosis directly, or is secondary to other intraoperative variables affecting acidosis. The clinical utility of rFVIIa in acidotic patients also requires further investigation. | 01/08/2007 | |
| Systemic anticoagulant effect of low-dose subcutaneous unfractionated heparin as determined using thrombelastography
SJ. Matzelle, NM. Gibbs, W. Weightman, M. Sheminant, R. Rowe, S. Baker
SUMMARY: In an observational study using heparinase-modified thrombelastography, we investigated the percentage of elective cardiothoracic surgical patients receiving low-dose unfractionated heparin (5000 IU 12 hourly subcutaneously) who had a demonstrable systemic heparin effect.
Blood samples were obtained at induction from 40 adult elective cardiothoracic surgical patients who had received 5000 IU unfractionated heparin subcutaneously within six hours. Simultaneous kaolin and heparinase-modified thrombelastographies were run on all samples. Fourteen patients (35%; 95% CI: 20 to 50%) had a demonstrable heparin effect (defined as a kaolin thrombelastography R time >25% longer than the heparinase-modified control). Their mean±SD kaolin thrombelastography R time was 13.6±5.9 minutes (normal range 4 to 8 minutes) vs. 7.1±2.0 minutes for the heparinase-modified controls. In 10 patients the thrombelastography R times were >50% longer and in four patients >100% longer, than their respective heparinase-modified controls. In a post hoc analysis, there was little correlation between the extent of the prolongation and patient age (r=0.02), weight (r=-0.31), preoperative creatinine (r=-0.17), or time since administration of heparin (r=0.14).
These results indicate that about one third of patients who have received low-dose unfractionated heparin subcutaneously within six hours have a demonstrable heparin effect. The potential for this effect should be considered if central neural blockade is planned. | 01/08/2007 | |
| Nitric oxide production is more prominent in off-pump than in on-pump coronary artery bypass surgery
C. Mitaka, K. Yokoyama, T. Imai
SUMMARY: The aim of our study was to elucidate the extent to which cardiopulmonary bypass contributes to endogenous nitric oxide (NO) production in patients undergoing coronary artery bypass grafts (CABG). One-hundred-and-sixteen patients undergoing elective CABG with cardiopulmonary bypass (on-pump, n=66) and without cardiopulmonary bypass (off-pump, n=50) were included. Urinary nitrite/nitrate (NOx) excretion was measured as an index of endogenous NO production during the first two postoperative days. Haemodynamic profiles, serum CK-MB and C-reactive protein (CRP) concentrations were measured after the operation. There was no significant difference in urinary NOx/creatinine (Cr) excretion on day one post CABG. The mean urinary NOx/Cr excretion ratio significantly (P <0.01) decreased from days one to two in the on-pump group, but not in the off-pump group. The mean urinary NOx/Cr excretion ratio was significantly (P <0.01) higher in the off-pump group (0.51±0.26 μmol/mg) than in the on-pump group (0.38±0.20 μmol/mg) on day two. The mean serum CRP concentration was also significantly (P <0.01) higher in the off-pump group than in the on-pump group on day two. There was no significant difference in the mean cardiac index or the mean systemic vascular resistance index between the two groups after surgery. The mean serum CK-MB concentration was significantly (P <0.05) lower in the off-pump group than in the on-pump group on days one and two. These findings suggest that endogenous NO production is stimulated by a surgical inflammatory response and that the cardiopulmonary bypass procedure per se is not the inciting stimulus for NO production in patients undergoing CABG. | 01/08/2007 | |
| Ropivacaine 0.25% is as effective as bupivacaine 0.25% in providing surgical anaesthesia for lumbar plexus and sciatic nerve block in high-risk patients: preliminary report
A. Kocum, A. Turkoz, H. Ulger, M. Sener, G. Arslan
SUMMARY: Ropivacaine is potentially less cardiotoxic and neurotoxic than bupivacaine. The aim of this study was to compare the effectiveness of ropivacaine 0.25% and bupivacaine 0.25% for surgical anaesthesia and postoperative analgesia during lumbar plexus and sciatic nerve block in high-risk patients. We performed combined lumbar plexus and sciatic nerve blockade on 62 consecutive ASA III or IV patients undergoing unilateral hip or femur surgery. The first 30 patients received bupivacaine (Group 1) and the remaining 32 patients received ropivacaine (Group 2). Perioperative management was otherwise similar. The groups were compared for the time of onset of the block, additional analgesics and sedatives required, time from end of surgery to the first analgesic requirement and the need for rescue analgesia. Ninety percent (29/32) of the patients in the ropivacaine group and 86% (26/30) of the patients in the bupivacaine group reached surgical anaesthesia. The time from the end of the surgery to the first analgesic requirement was similar between the two groups (10.3±5.2 hours for ropivacaine, 11.2±4.6 hours for bupivacaine). There was no statistically significant difference between the two groups in any of the measured variables (P >0.05). The results of this preliminary study suggest that ropivacaine 0.25% is as effective as bupivacaine 0.25% when used for blocking lumbar plexus and sciatic nerve in high-risk patients undergoing hip or femur surgery. | 01/08/2007 | |
| Combining Sequential Organ Failure Assessment (SOFA) score with Acute Physiology and Chronic Health Evaluation (APACHE) II score to predict hospital mortality of critically ill patients
KM. Ho
SUMMARY: The ability to accurately adjust for the severity of illness in outcome studies of critically ill patients is essential. Previous studies have showed that Sequential Organ Failure Assessment (SOFA) score and Acute Physiology and Chronic Health Evaluation (APACHE) II score can predict hospital mortality of critically ill patients. The effects of combining these two scores to predict hospital mortality of critically ill patients has not been evaluated. This cohort study evaluated the performance of combining the APACHE II score with SOFA score in predicting hospital mortality of critically ill patients. A total of 1,311 consecutive adult patients admitted to a tertiary 22-bed multidisciplinary intensive care unit (ICU) in Western Australia were considered. The APACHE II, Admission SOFA, Delta SOFA and maximum SOFA score were all related to hospital survival in the univariate analyses. Combining Max SOFA (area under receiver operating characteristic curve 0.875 vs. 0.858, P=0.014; Nagelkerke R2: 0.411 vs. 0.371; Brier Score: 0.086 vs. 0.090) or Delta SOFA score (area under receiver operating characteristic curve 0.874 vs. 0.858, P=0.003; Nagelkerke R2: 0.412 vs. 0.371; Brier Score: 0.086 vs. 0.090) with the APACHE II score improved the discrimination and overall performance of the predictions when compared with using the APACHE II score alone, especially in the emergency ICU admissions. Combining Max SOFA or Delta SOFA score with the APACHE II score may improve the accuracy of risk adjustment in outcome studies of critically ill patients. | 01/08/2007 | |
| In-hospital cardiac arrest: different wards show different survival patterns
S. Smith, EA. Shipton, JE. Wells
SUMMARY: The purpose of the study was to investigate the characteristics and outcomes of in-hospital cardiac arrests that occurred outside of the hospital critical care areas. A prospective register of adult in-hospital cardiac arrests occurring in non-critical care areas of Christchurch Hospital, Christchurch, New Zealand, from January 2001 to December 2004 was compiled. Two-hundred-and-forty-three cardiac arrests were recorded in this period. The overall return of spontaneous circulation was 38.7% (CI 32.6, 44.8) and survival to discharge was 21.0% (CI 15.9, 26.1). Comparison of clinical areas showed that the percentage with successful resuscitation and the percentage with survival to discharge were highest in the cardiology wards (52.2%, 41.3%) and lowest in the medical wards (24.9%, 8.8%). After taking account of rhythm, age, gender and time of day, differences between clinical areas were slightly reduced. Cardiology wards, however, still had a higher resuscitation percentage than medical wards (P=0.03) and a higher percentage with survival to discharge than all other areas (P=0.005 overall, P ≤0.05 for each individual comparison). Reporting of hospital-wide survival rates does not accurately reflect the survival rates in a variety of specific clinical areas. The analysis of outcomes across different clinical areas at Christchurch Hospital revealed differences in outcomes and therefore the clinical experience of staff in those areas. These differences have implications for the resuscitation training of health professionals. The further development of national resuscitation registries may allow more specific analysis of outcomes in different clinical areas. | 01/08/2007 | |
| Continuous venovenous haemofiltration using a citrate buffered substitution fluid
M. Schmitz, G. Taskaya, J. Plum, M. Hennersdorf, C. Sucker, B. Grabensee, GR. Hetzel
SUMMARY: Different methods of regional anticoagulation using citrate in continuous renal replacement therapy have been described in the past. However, these procedures were usually very complex or did not reach modern requirements for effective continuous renal replacement therapy. Furthermore, little is known about long-term acid-base stability and citrate levels during the treatment. We describe a system in which citrate is used both as anticoagulant and as the sole buffer substance in continuous venovenous haemofiltration. Our citrate-containing, calcium-free substitution fluid was used in predilution mode with a constant ratio between blood flow (120 to 150 ml/min) and substitution flow (2400 to 3000 ml/hour). Anticoagulation was limited to the extracorporeal circuit. Twenty patients with acute renal failure on mechanical ventilation were treated, four for eight hours, four for 24 hours and 12 as long they needed continuous renal replacement therapy (9.6±5.0 days, range 4.0 to 39.3 days).
We achieved stable acid-base and electrolyte balance in all patients. We observed no bleeding complications (patient activated clotting time 112.4±17.1 s, post-filter circuit activated clotting time 270.5±80.3 s) and achieved appropriate filter life times (48.6±13.2 h).
Predilution, citrate-based substitution fluid provides both anticoagulation within the extracorporeal circuit and control of acid-base balance in critically ill patients at risk of bleeding in acute renal failure. It is easy to apply and safe. Clearance can be varied as long as a constant ratio between blood and substitution flow is maintained. | 01/08/2007 | |
| Anaesthesia for hemipelvectomy—a series of 49 cases
R. Molnar, G. Emery, PFM. Choong
SUMMARY: We undertook an audit of 49 consecutive hemipelvectomies performed for primary or secondary malignancy. Combined epidural and general anaesthesia was used in 41 patients. The operations were long (range 90 to 600 minutes). The median crystalloid requirement was 8500 ml (range 1000 to 42000 ml) and a median of seven units of packed red blood cells were transfused (range 0 to 44 units). All measures of coagulation were normalised by the first postoperative day using fresh frozen plasma, platelets and cryoprecipitate. Warmed blood was administered at high flow rates using a custom designed system consisting of a roller pump and high capacity fluid warmer. Thirty-five patients were managed postoperatively in the intensive care unit, of whom 31 remained intubated for postoperative ventilation. In 41 patients, postoperative pain management was by a continuous epidural infusion of local anaesthetic and opioid. The average duration of infusion was 4.25 days (range 3 to 6 days). One patient died during surgery from complications relating to massive blood loss, 14 had wound infections and one had an acute brain syndrome. There was significant utilisation of resources involving anaesthesia, surgery, intensive care and blood transfusion services. Anaesthesia for hemipelvectomy is challenging because of the extensive tissue trauma involved, the potential for massive blood loss and the potential for severe postoperative pain. The perioperative management necessitates care from a well coordinated, directed and focused healthcare team. | 01/08/2007 | |
| Comparative safety and efficacy of two high dose regimens of oral paracetamol in healthy adults undergoing third molar surgery under local anaesthesia
M. Zacharias, RK. De Silva, J. Hickling, NJ. Medlicott, DM. Reith
SUMMARY: This study compared the efficacy and safety of single oral doses of 60 mg/kg and 90 mg/kg paracetamol in fit young adult patients undergoing third molar extractions. The study was a randomised, blinded, crossover design on 20 young, fit adults. Paracetamol was administered 30 minutes prior to the surgical extraction of the teeth, which was done under intravenous sedation and local anaesthesia. There were no clinically or statistically significant differences in the pain scores between 60 mg/kg or 90 mg/kg doses until the intake of rescue analgesics. There was a reduction in factor VII activity with 90 mg/kg dose compared to 60 mg/kg dose. It may be concluded that the 90 mg/kg dose, though safe, does not offer any advantages over 60 mg/kg dose of paracetamol in young fit adults undergoing third molar surgery. | 01/08/2007 | |
| Patterns of sevoflurane use in a children’s hospital: the effects of a simple educational intervention
M. Lethbridge, A. Bouckley, NA. Chambers
SUMMARY: We conducted a prospective observational study of sevoflurane use over a four-week period at our tertiary referral children’s hospital. Sevoflurane vaporisers were weighed before and after all general anaesthesia sessions and anaesthesia time intervals recorded. Midway through the audit, the initial findings were presented to the department with a brief reminder of ways to reduce sevoflurane use. These included recommendations for fresh gas flows and use of alternative agents during maintenance. Sevoflurane use then continued to be audited over a further two-week period. Anaesthesia in induction rooms accounted for 60% of total sevoflurane use but involved only 15% of total general anaesthetic time. Thus sevoflurane was used eight times faster in the induction rooms when compared to operating theatres. There was a 53% reduction in the rate of use of sevoflurane after the educational intervention, with an 87% reduction in in-theatre use and a 31% reduction in induction room use. This represents a potential saving of $108,120 per annum in our institution. Workloads before and after the educational intervention were comparable. A more complete cost benefit analysis of this initiative would include the costs of alternative agents and any clinical disadvantages incurred and would be seen in the context of the overall health budget. This was beyond the scope of this project. Clinicians can be relatively complacent about financial accountability. In this study, a simple educational reminder halved sevoflurane use in the short term. This study suggests that specific reminders or recommendations about anaesthetic technique in the induction rooms may be indicated. | 01/08/2007 | |
| | Clinical Technique | | |
| The shoulder block: a new alternative to interscalene brachial plexus blockade for the control of postoperative shoulder pain
DJ. Price
SUMMARY: This report describes the development of the shoulder block, an alternative to interscalene brachial plexus blockade for the control of postoperative pain following shoulder surgery. Included is a review of the relevant anatomy of the shoulder joint and its associated structures. Two nerves provide the bulk of the innervation to this area: the suprascapular nerve and the axillary (circumflex) nerve. The shoulder block technique involves selective blockade of both of these nerves instead of general blockade of the entire brachial plexus via the interscalene route. The technique of Meier is used to block the suprascapular nerve in the supraspinous fossa. No descriptions of axillary nerve block were available in the literature, so a technique for blocking this nerve as it travels across the posterior surface of the humerus was developed and is described, along with a discussion of the author’s initial clinical experience. | 01/08/2007 | |
| | Survey | | |
| Patients’ knowledge of the qualifications and roles of anaesthetists
AR. Braun, K. Leslie, C. Morgan, S. Bugler
SUMMARY: Patients’ knowledge of anaesthetists’ qualifications and roles remains inaccurate despite the efforts of professional bodies worldwide. However, patients have not been surveyed on this subject in Australia for more than 20 years. We therefore surveyed 200 patients attending the pre-admission clinic prior to elective non-cardiothoracic surgery in an Australian teaching hospital to determine current knowledge. Most (90.5%) patients stated that anaesthetists are medically qualified and 83.5% stated that they are medical specialists. Younger age, an English-speaking background and previous experience with surgery predicted knowledge of anaesthetists’ qualifications. Most patients believed that anaesthetists work in the operating theatre and are continually present during surgery, but few recognised their leading role in the care of patients during surgery or their other roles outside the operating theatre. Increased efforts are required to inform patients about the roles of anaesthetists in their care. | 01/08/2007 | |
| | Audit | | |
| Prospective audit comparing intrathecal analgesia (incorporating midazolam) with epidural and intravenous analgesia after major open abdominal surgery
MA. Duncan, J. Savage, AP. Tucker
SUMMARY: 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. | 01/08/2007 | |
| Airway management equipment in a metropolitan region: an audit
PA. Baker, GL. Hounsell, ME. Futter, BJ. Anderson
SUMMARY: Difficult airway equipment containers are commonly found in operating rooms, but the availability of airway equipment beyond that environment is unknown. Using the Difficult Airway Society (U.K.) and American Society of Anesthesiologists’ guidelines, we conducted an inspection audit of airway equipment at all anaesthetic sites in our region. Staff knowledge about the equipment was assessed and feedback was provided to each site.
Eighteen of the 42 sites had an airway container. Equipment for an unexpected difficult intubation, according to the guidelines, was deficient at all sites. Equipment to detect oesophageal intubation was inadequate. Locations remote from the operating suite lacked emergency invasive airway equipment and were, on average, a 4.3 minute walk from the nearest appropriate equipment. Two clinics had no emergency invasive airway equipment. Half of the airway containers with check lists had items missing. One third of the items with an expiry date were expired. Quality control and implementation of airway guidelines could rectify these deficiencies. Anaesthesia organisations should be encouraged to publish detailed equipment guidelines. | 01/08/2007 | |
| | Equipment | | |
| Investigation of a new echogenic needle for use with ultrasound peripheral nerve blocks
RK. Deam, R. Kluger, MJ. Barrington, CA. McCutcheon
SUMMARY: A new ‘texturing method’ has been developed for nerve block needles in an attempt to improve the ultrasonic image of the needles. Using a synthetic phantom, these textured needles were compared to currently available needles. The textured needle had improved visibility under ultrasound. This type of needle may assist the anaesthetist perform ultrasound-guided regional anaesthesia. | 01/08/2007 | |
| | Education and Training | | |
| Learning and teaching in small groups: characteristics, benefits, problems and approaches
RW. Jones
SUMMARY: Small group learning may be defined as a group of learners demonstrating three common characteristics; active participation, a specific task and reflection. This article provides an overview of small group learning and teaching, describes the characteristics of this form of small group work, benefits, problems, potential causes of less than optimal sessions, and summarises specific approaches. These include tutorials, free-discussion groups, brainstorming, snowballing, buzz groups, paired (or one-to-one) discussion, clinical teaching, simulations, seminars, plenary sessions, problem-based learning, team-based learning, role plays, games and IT approaches. The article concludes with an emphasis on the importance of the teacher and a check list for use when planning, teaching and evaluating a small group session. | 01/08/2007 | |
| | Point of View | | |
| Perioperative epidural anaesthesia and analgesia—an appraisal of its role
MJ. Davies
SUMMARY: Perioperative epidural anaesthesia and analgesia (PEA) has become controversial because of its doubtful effect on patient outcome and its serious complications. These scientific considerations have been affected by the changing medicolegal climate in Australia and has led to a reappraisal of this technique in our practice of anaesthesia. Many anaesthetists are now uncertain about indications, consent requirements, optimal management and the prevention and early detection of complications of PEA. The aim of this paper is to present a personal perspective of the place and use of PEA in current anaesthetic practise. The primary indication for PEA should be pain relief for open abdominal or thoracic surgery because there is level 1 evidence that it provides better analgesia than parenteral opioids. There is reasonable evidence that outcome is improved but the studies are conflicting. Coagulation status needs to be assessed carefully before the insertion and removal of epidural catheters. Consent issues are difficult in practice, both from the timing and the content of the information. The decrease in the use of PEA may paradoxically result in more complications as loss of expertise becomes an issue. PEA is labour intensive and therefore needs the support of an Acute Pain Service in order to use this technique safely and recognise problems early. Permanent neurological complications are the most feared complication of this technique but early recognition of these problems can improve outcome. These complications need to be balanced against the potentially serious hypoxaemia associated with parenteral opioids used for postoperative pain relief. | 01/08/2007 | |
| | Case Report | | |
| Nocardia sepsis in a multigravida with systemic lupus erythematosus and autoimmune hepatitis
CL. Cassar
SUMMARY: This report describes a pregnant woman with systemic lupus erythematosus and autoimmune hepatitis who presented with threatened labour and acute renal failure. She developed respiratory distress, haematemesis and became coagulopathic. Intrauterine death occurred and she was admitted to the intensive care unit after caesarean section. She suffered sudden cardiovascular collapse and succumbed. At autopsy, Nocardia was cultured from multiple renal abscesses. The co-existence of Nocardia sepsis, systemic lupus erythematosus, autoimmune hepatitis and pregnancy are discussed. This case illustrates diagnostic challenges associated with Nocardia infection in the presence of co-existing disease. | 01/08/2007 | |
| Postoperative paraplegia coincident with single shot spinal anaesthesia
BW. LaFerlita
SUMMARY: Paraplegia is a rare but serious complication of spinal anaesthesia. We report an 83-year-old patient who developed anterior spinal artery syndrome resulting in paraplegia some 24 hours after undergoing spinal anaesthesia for a Moore’s hemiarthroplasty. Return of neurologic function was documented prior to the onset of paralysis, with magnetic resonance imaging evidence suggestive of spinal cord infarction. | 01/08/2007 | |
| Posterior fossa haematoma following sudden decompression of acute hydrocephalus resulting from neuroendoscopy
H. Prabhakar, Z. Ali, GP. Rath
SUMMARY: We report a case of a 47-year-old male undergoing endoscopic removal of a third ventricular colloid cyst. After uneventful surgery, the patient remained drowsy and was transferred to the intensive care unit for supportive care. In the postoperative period, the patient developed hydrocephalus due to clot in the region of the cyst. A posterior fossa haematoma and further neurological deterioration complicated external ventricular drainage, presumably due to sudden intracranial hypotension. Gradual ventricular decompression is recommended to reduce the risk of this complication. | 01/08/2007 | |
| Sildenafil may facilitate weaning in mechanically ventilated COPD patients: a report of three cases
I. Stanopoulos, N. Manolakoglou, G. Pitsiou, I. Trigonis, EA. Tsiata, AK. Boutou, PK. Kontou, P. Argyropoulou
SUMMARY: We report three cases of mechanically ventilated chronic obstructive pulmonary disease patients who were intubated due to an exacerbation of their disease and who presented with repeated spontaneous breathing trial failures. Patients were given 50 mg of sildenafil through the nasogastric tube, under close monitoring of haemodynamic and ventilatory parameters. After sildenafil, pulmonary artery pressure, pulmonary artery occlusion pressure, the respiratory frequency to tidal volume ratio and the PaCO2 - PETCO2 (arterial minus end-tidal carbon dioxide pressure) decreased. Cardiac output increased in two of the patients, while all of them were successfully extubated. This is the first report of successful extubation after sildenafil use. | 01/08/2007 | |
| | Abstract of ANZCA | | |
The authors of these abstracts have attested to receipt of appropriate Ethics Committee approval and to significant contribution. Abstracts have been subject to editorial inspection only. Other papers of a review or general nature were also presented. Certain specific papers for which a suitable abstract was not available, or which are to be published elsewhere, have not been included.
-Editor |
| WOUND CATHETER INFUSION OF LOCAL ANAESTHETIC FOR UPPER ABDOMINAL LAPAROTOMY
D. Blackford, CR. Chilvers, I. Robertson
| 01/08/2007 | |
| THE EFFECT OF COMMUNICATION ON PAIN DURING VENOUS CANNULATION: A DOUBLE BLIND RANDOMISED CONTROLLED TRIAL
T. Bown, J. Dutt-Gupta, AM. Cyna
| 01/08/2007 | |
| THE ABILITY OF ANAESTHETISTS TO IDENTIFY GENERIC MEDICATIONS FROM TRADE NAMES
DEP. Bramley
| 01/08/2007 | |
| DO PATIENTS WITH A HISTORY OF PONV HAVE REDUCED VOLATILE ANAESTHETIC REQUIREMENTS?
D. Brown, M. Reeves
| 01/08/2007 | |
| NON PHARMACOLOGICAL INTERVENTIONS TO FACILITATE INDUCTION OF ANAESTHESIA IN CHILDREN: AN OBSERVATIONAL STUDY
A. Carlyle, P. Ching, AM. Cyna
| 01/08/2007 | |
| TSE “MASK”: A TECHNICALLY SIMPLE AND EFFECTIVE FACE TENT IMPROVES OXYGENATION IN PATIENTS DURING UPPER ENDOSCOPY
S. Cohen, A. Kuppusamy, J. Nezgoda, D. New, C. Hunter, J. Tse
| 01/08/2007 | |
| HELPFUL OR HURTFUL?—COMMUNICATIONS UTILISED BY ANAESTHETISTS
AM. Cyna, ML. Andrew, V. Taylor, P. Yip
| 01/08/2007 | |
| NON-PHARMACOLOGICAL INTERVENTIONS FOR INDUCTION OF ANAESTHESIA IN CHILDREN: A SYSTEMATIC REVIEW
AM. Cyna, P. Middleton, P. Yip, A. Carlyle
| 01/08/2007 | |
| BIS-AWAKE IN CHILDREN USING THE LATEST PAEDIATRIC SENSOR AND ALGORITHM
A. Davidson, T. Kwok
| 01/08/2007 | |
| ANAESTHESIA FOR INFANT INGUINAL HERNIA REPAIR: A PILOT AUDIT
A. Davidson, G. Frawley, S. Sheppard, R. Hunt, P. Hardy
| 01/08/2007 | |
| HUMAN FACTORS BASED DEVELOPMENT OF A COMPUTERISED ANAESTHETIC CONSULTATION
JM. Davies, S. MacKillop, JK. Caird, K. Drader
| 01/08/2007 | |
| AUDIT OF PERIOPERATIVE MANAGEMENT AND OUTCOME OF PROXIMAL HIP SURGERY IN A DISTRICT HOSPITAL
BA. El-Behesy, R. Hu
| 01/08/2007 | |
| EVALUATION OF ‘CODE BLUE’ MANAGEMENT IN A TERTIARY WOMEN’S HOSPITAL
WLL. Fun, E. Lew, WHL. Teoh, CF. Yim
| 01/08/2007 | |
| COMPARISON OF MIDAZOLAM AND REMIFENTANIL AS A PREMEDICATION TO REDUCE ETOMIDATE-INDUCED MYOCLONUS
S. Han, C. Kim
| 01/08/2007 | |
| BASE EXCESS IN INTENSIVE CARE UNIT PATIENTS WITH EMERGENCY ABDOMINAL OPERATIONS
WS. Ho, WW. Yan, B. Tom, CK. Tong
| 01/08/2007 | |
| MORTALITY OUTCOMES FOR ACUTE MYOCARDIAL INFARCTIONS ACROSS CALIFORNIA HOSPITALS FROM 1991 TO 1998
R. Hsia
| 01/08/2007 | |
| RELATIVE EFFICIENCY OF WARMING DEVICES DURING LAPOROSCOPIC CHOLECYSTECTOMY
VR. Kadam, D. Moyes
| 01/08/2007 | |
| THE EFFECT OF ASA STATUS AND THE MAGNITUDE OF SURGERY ON LONG TERM SURVIVAL IN THE ABSENCE OF MALIGNANCY
RR. Kennedy, F. Frizelle
| 01/08/2007 | |
| THE EFFECT OF TRIGG’S TRACKING VARIABLE ON THE DETECTION OF CHANGES
RR. Kennedy, D. Cathcart
| 01/08/2007 | |
| DIFFICULT LMA INSERTION—ANALYSIS OF 29 CASES
CK. Koay, SM. Tan, PH. Teoh
| 01/08/2007 | |
| ASSESSMENT OF SKIN CONDUCTANCE AS A MEANS OF PREDICTING HYPOTENSION AFTER INDUCTION OF SPINAL ANAESTHESIA IN THE ELDERLY
T. Ledowski, J. Preus, S. Lauer, MJ. Paech
| 01/08/2007 | |
| STIMULATION OF THE WRIST P6 ACUPOINT TO PREVENT POSTOPERATIVE NAUSEA AND VOMITING: AN UPDATE
A. Lee, L. Fan, M. Done
| 01/08/2007 | |
| PERIOPERATIVE TEMPERATURE AUDIT IN THE TROPICS
K. Lee, P. Blum
| 01/08/2007 | |
| FAILED EPIDURAL ‘TOP-UPS’ FOR EMERGENCY CAESAREAN SECTIONS; INCIDENCE AND RISK FACTOR
SY. Lee, E. Lew, Y. Lim, A. Sia
| 01/08/2007 | |
| A NEW BEDSIDE TECHNIQUE FOR DETECTING INFERIOR VENA CAVA COMPRESSION IN TERM PARTURIENTS
SWY. Lee, KS. Khaw, WDN. Kee, TY. Leung, SSY. Ho, MTC. Ying, LAH. Critchley
| 01/08/2007 | |
| PLASMA MONOCYTE CHEMOATTRACTANT PROTEIN-1 CONCENTRATIONS DURING ON-PUMP OR OFF-PUMP CORONARY ARTERY BYPASS GRAFTING SURGERY
T. Lin, C. Li, C. Wong, S. Ho
| 01/08/2007 | |
| IS THE AUDITORY EVOKED POTENTIAL OR BISPECTRAL INDEX RELIABLE FOR MONITORING THE SEDATION LEVEL IN SURGICAL INTENSIVE CARE PATIENTS?
C. Lu, S. Ho, C. Wong, W. Liaw
| 01/08/2007 | |
| THE PRICE OF OPTIMISING RATIONAL PATHOLOGY TEST ORDERING IS ETERNAL VIGILANCE
R. MacPherson
| 01/08/2007 | |
| USE OF KETAMINE FOR SURGICAL PROCEDURES IN DISASTER MEDICINE: THE 2005 KASHMIR EARTHQUAKE EXPERIENCE
JM. Mulvey, AA. Qadri, MA. Maqsood
| 01/08/2007 | |
| IS STAIR-CLIMBING A VALID TEST OF AEROBIC FUNCTION FOR PREOPERATIVE EVALUATION OF RISK?
PO. Older, J. Patterson
| 01/08/2007 | |
| THE OXIDATIVE STRESS OF HYPERGLYCAEMIA AND THE INFLAMMATORY PROCESS IN ENDOTHELIAL CELLS
G. Ong, S. Yan, R. Qvist, A. Vincent, CS. Pheng
| 01/08/2007 | |
| THE AUSTRALASIAN OBSTETRIC GENERAL ANAESTHESIA FOR CAESAREAN SECTION SURVEY
MJ. Paech, O. Clavisi, KL. Scott, NJ. McDonnell, ANZCA Trials Group
| 01/08/2007 | |
| MEASUREMENT OF ANAESTHETIC AGENTS IN BLOOD USING A CONVENTIONAL CLINICAL GAS ANALYSER
P. Peyton, M. Chong, G. Robinson, CR. Stuart-Andrews
| 01/08/2007 | |
| EFFECTS OF PULMONARY CAPILLARY PRESSURE ON LUNG MECHANICS DURING NEGATIVE-PRESSURE VENTILATION OF ISOLATED PERFUSED RAT LUNGS
A. Regli, BS. von Ungern-Sternberg, F. Petak, F. Fontao, W. Habre
| 01/08/2007 | |
| PREDICTORS OF PREOPERATIVE ANXIETY IN CHILDREN UNDERGOING GENERAL ANAESTHESIA AND SURGERY
E. Seet, SB. Leong, S. Tan
| 01/08/2007 | |
| PRE-EXISTING COGNITIVE IMPAIRMENT IN PATIENTS FOR ELECTIVE CORONARY ARTERY BYPASS GRAFT SURGERY
B. Silbert, DA. Scott, L. Evered, M. Lewis, P. Maruff
| 01/08/2007 | |
| IMPLEMENTATION OF A MENTOR PROGRAMME: LESSONS AND TIPS
N. Smith
| 01/08/2007 | |
| INCIDENCE AND CHARACTERISTICS OF FAILED SPINAL ANAESTHESIA FOR CAESAREAN DELIVERY
BL. Sng, Y. Lim, ATH. Sia
| 01/08/2007 | |
| SERIOUS TRANSFUSION INCIDENT REPORTING: A PILOT STUDY
L. Stevenson, D. Beilby, K. Botting, J. Domanski, C. Hogan, G. Magrin, E. Maxwell, R. Rogers, C. Smith, N. Waters, D. Wilks, E. Wood, L. McNicol
| 01/08/2007 | |
| THE RAE™ PREFORMED ORAL TRACHEAL TUBE IN BARIATRIC ANAESTHESIA:
AN OBSERVATIONAL STUDY
A. Sultana
| 01/08/2007 | |
| A NATIONAL SURVEY OF ANALGESIC PRESCRIBING PRACTICES IN THE ACUTE POSTOPERATIVE PAIN PATIENT
J. Trinca, K. McIntosh, O. Clavisi, P. Macintyre, S. Schug, A. Wai
| 01/08/2007 | |
| PREEMPTIVE ANALGESIC EFFECT OF FENTANYL ON TOURNIQUET PAIN
M. Uchida, K. Takeda
| 01/08/2007 | |
| SHOULD THE USE OF THE MODIFIED JACKSON REES T-PIECE BREATHING SYSTEM BE ABANDONED IN PRESCHOOL CHILDREN?
BS. von Ungern-Sternberg, S. Saudan, A. Regli, W. Habre
| 01/08/2007 | |
| PROPOFOL VERSUS KETAMINE SEDATION: IMPACT ON FUNCTIONAL RESIDUAL CAPACITY AND VENTILATION HOMOGENEITY
BS. von Ungern-Sternberg, A. Regli, F. Frei, J. Hammer, TO. Erb
| 01/08/2007 | |
| SAFETY AND EFFICACY OF PATIENT CONTROLLED EPIDURAL ANALGESIA FOLLOWING PAEDIATRIC SPINAL SURGERY
BS. von Ungern-Sternberg, S. Saudan, D. Ceroni, P. Meyer, A. Kaelin, W. Habre
| 01/08/2007 | |
| THE IMPACT OF TRAINED ANAESTHESIA ASSISTANCE ON ERROR RATES IN ANAESTHESIA
JM. Weller, A. Merry, J. Janssen, G. Warman, B. Robinson
| 01/08/2007 | |
| THE USE OF EPIDURAL ANALGESIA PRE AND POST MASTER STUDY IN A NEW ZEALAND TERTIARY HOSPITAL
GC. Werrett, R. French, R. Craig, H. Horton
| 01/08/2007 | |
| AIMS ANAESTHESIA: A COMPARATIVE ANALYSIS OF THE FIRST 2000 AND THE MOST RECENT 1000 INCIDENT REPORTS
J. Williamson, B. Runciman, P. Hibbert, K. Benveniste
| 01/08/2007 | |
| A USER SURVEY OF THE IMPACT OF CELLPHONES ON COMMUNICATION IN THE OPERATING ROOM AND INTENSIVE CARE UNIT ENVIRONMENTS
YL. Wong, KJ. Chin, BH. Tan, S. Loo, GF. Chin
| 01/08/2007 | |
| PASSIVE OBSERVATION OF HIGH FIDELITY SIMULATION DOES NOT IMPROVE PERFORMANCE BY MEDICAL STUDENTS IN A CARDIAC ARREST SCENARIO
PF. Yau, R. Molnar, D. Paltridge
| 01/08/2007 | |
| PRELIMINARY EVALUATION OF A NEW DISPOSABLE LARYNGOSCOPE
KF. Yee
| 01/08/2007 | |
| THE RELATIONSHIP BETWEEN SURGICAL ANTIBIOTIC PROPHYLAXIS GUIDELINES AND CURRENT PRACTICE AT AUSTIN HEALTH
X. Yin, DA. Story, DA. Cowie
| 01/08/2007 | |
| UNDERSTANDING OURSELVES: ISSUES CONFRONTING REGISTRARS AND HOW THEY COPE
A. Young, M. Salzberg, DA. Scott
| 01/08/2007 | |
| HAEMOSTATIC RESUSCITATION: RECENT ADVANCES LEARNED FROM TREATING COMBAT TRAUMA PATIENTS IN THE MIDDLE EAST
S. Zalstein
| 01/08/2007 | |
| | Correspondence | | |
| Re: Long term neurological complications associated with surgery and peripheral nerve blockade: outcomes after 1065 consecutive blocks
CJ. Peady
| 01/08/2007 | |
| Re: Cardiac arrest during continuous psoas compartment block for hip surgery
CJ. Peady
| 01/08/2007 | |
| Re: Cardiac arrest during continuous psoas compartment block for hip surgery—Reply
G. Zanette
| 01/08/2007 | |
| Safety of the psoas compartment block?
D. Cattano
| 01/08/2007 | |
| Ultrasound-guided transversus abdominis plane (TAP) block
PD. Hebbard, Y. Fujiwara, Y. Shibata, CF. Royse
| 01/08/2007 | |
| Audit of "rescue" analgesia using TAP block
PD. Hebbard
| 01/08/2007 | |
| Successful long-term treatment of a patient with long-standing Raynaud’s disease by extradural bupivacaine block
MA. Hashem, R. Lewis
| 01/08/2007 | |
| Bite-block tube for airway-management during electroconvulsive therapy
W. Lederer, JF. Kinzl
| 01/08/2007 | |
| Use of colonoscopic polyp snare to retrieve an endotracheal foreign body
D. Dunbar, M. Rowland, D. Jones
| 01/08/2007 | |
| Intraventricular bleed is not the only culprit!
K. Sriganesh, KP. Unnikrishanan
| 01/08/2007 | |
| Bispectral index monitoring may have alternate uses!
H. Prabhakar, GP. Rath
| 01/08/2007 | |
| Unilateral mydriasis and hypertensive crisis during nasal surgery
R. Nikandish, S. Taregh
| 01/08/2007 | |
| Australian and New Zealand guidelines for preoperative fasting
DM. Woods, R. MacPherson
| 01/08/2007 | |
| Another cause of leak during propofol target controlled infusion
K. Sriganesh, PR. Suneel, PK. Dash
| 01/08/2007 | |
| A severe case of transoral impalement injury
H. Singh, JP. Paul, AC. Marshall
| 01/08/2007 | |
| | Book Review | | |
| Examination Intensive Care and Anaesthesia. A guide to Intensivist and Anaesthetist Training
PG. Ragg
| 01/08/2007 | |
| Management of acute and chronic neck pain: An evidence-based approach
JP. Bradley
| 01/08/2007 | |
| Atlas of Regional Anaesthesia
TJG. Pavy
| 01/08/2007 | |
| Obstetric and Gynecologic Anesthesia
R. Gebert
| 01/08/2007 | |
| Transesophageal Echocardiography Multimedia Manual-A Perioperative Transdisciplinary Approach
R. Kluger
| 01/08/2007 | |
| Textbook of Regional Anesthesia and Acute Pain Management
P. Forrest
| 01/08/2007 | |
| How to Survive in Anaesthesia. A guide for trainees
A. Sultana
| 01/08/2007 | |