Anaesthesia

Trauma remains a leading cause of death across all age groups. Thoracic injury is a contributing cause in approximately half of these. Despite being potentially life threatening, most thoracic trauma is managed nonoperatively or with an intercostal catheter. Only 10% of thoracic trauma patients will require emergency thoracotomy. Many more will undergo emergency or urgent surgical intervention for coexisting injuries. Thoracic injuries are dynamic. It is crucial for the anesthesiologist to continually reassess the patient, so that the manifestations of evolving injuries may be detected as early as possible and appropriate management decisions made. Up-to-date knowledge of injury patterns, mechanisms, pathophysiology, and operative and nonoperative management will facilitate optimal management of these patients.

Safe and effective response to blast injuries is enhanced by an understanding of the physics and applied pathophysiology of these events. The mechanisms of injury are presented, along with an interpretation of the clinical implications in the tactical environment.

We compared the incidence of postoperative complications in women (vs. men) in 4173 patients. Overall, women were almost twice as likely to report any postoperative complication (RR = 1.92, p < 0.0005). Specifically, they were 2.6 times more likely to report nausea and vomiting (p < 0.0005), 1.5 times more likely to report sore throat (p = 0.0001), 2.3 times more likely to report headache (p < 0.0005) and 2.4 times more likely to report backache (p = 0.0036). Whether these gender differences are due to a reporting bias, or whether in fact women are at greater risk of such complications, remains to be determined.

The 2015 Paris terrorist attacks were complex and coordinated. We analysed some of  the openly accessible information about the attack, including its planning and execution. We recognised opportunities for tactical medical responders around the world to learn from this event. We made no analysis or assessment of the actual tactical medical response to the situations, but attempted to recognise key components of what a safe and effective response could consider.

Background:  Terrorism is increasingly the aetiology of mass casualty incidents.  Improved prehospital response capability targeted to the unique characteristics of high threat incidents is an area of urgent focus.  Gaps in current knowledge coupled with inconsistent reporting and difficulties in accessing data create difficult conditions for capability enhancement. Methods: A systematic literature review was conducted to describe the characteristics of prehospital response to terrorism from 2011 -2017.  Papers were included if they described a prehospital response to a terrorist incident, were in English or translatable to English and full text was available. Results:  6115 records were located in the initial search of grey and published literature, with 71 retrieved for full text after screening of title and abstract.  23 papers were included in the final analysis, describing 6 separate terrorist attacks.  The majority of literature was published by physicians, all were from Weste...

We studied the use of intraoperative tape suggestion to improve the rate of cessation of smoking in 363 smokers who wanted to stop smoking. They were allocated randomly to hear a taped message encouraging them to stop smoking or to a blank tape, played during general anaesthesia. Overall 56 patients (15.4 %, 95 % confidence interval (CI) 11.7-19.1 %) had claimed to have stopped smoking at 2 months and 29 patients (8.0 %, 95 % CI 5.9-10.1 %) were confirmed to have stopped smoking at 6 months. There was no significant difference between the groups at either 2 or 6 months (risk ratios 1.06 and 1.09, respectively, P : 0.78). A preoperative : postoperative ratio of a visual analogue scale measuring the patient's motivation to stop smoking was not significantly different (control group 1.13 vs message group 1.10, P : 0.55). This study does not support the hypothesis that intraoperative tape suggestion can change smoking behaviour. (Br.

Objective: This prospective, observational, interventional study sought to determine if the introduction of resuscitative balloon occlusion of the aorta (REBOA) at an Australian adult major trauma centre would improve survival for major trauma patients. Methods: Patients aged 18-60 years, transported directly from scene with exsanguinating, sub-diaphragmatic haemorrhage and hypovolaemic shock (systolic BP <70 mmHg or

Background The standard process of obtaining informed consent sometimes prevents physicians or patients from participating in clinical trials, partly because they are concerned about eventual treatment allocation or the physician is concerned the patient might harbor some uncertainty about the best treatment. Alternative randomization methods have been advocated that may address these and other concerns. Methods After institutional ethics committee gave its approval, the authors interviewed 770 patients before operation and asked them to consider enrolling in a mock anesthesia trial. Patients were allocated randomly to one of five methods of randomization and consent: one-sided informed consent (the most common approach), prerandomized consent to experimental treatment, prerandomized consent to standard treatment, one-sided physician-modified informed consent, or one-sided patient-modified informed consent. Recruitment rates were compared and sociodemographic and perioperative predi...

The prevalence of diabetes mellitus (DM) is increasing rapidly. In 2011, it was estimated that 366 million people worldwide had DM with a projected increase to 522 million by 2030. Diabetes is one of the most common non-communicable diseases

Objective: To examine the effect of the "after-hours" (18:00-07:00) model of trauma care on a high-risk subgroup-patients presenting with acute traumatic coagulopathy (ATC). Design, participants and setting: Retrospective analysis of data from the Alfred Trauma Registry for patients with ATC presenting between 1 January 2006 and 31 December 2011. Main outcome measure: Mortality at hospital discharge, adjusted for potential confounders, describing the association between after-hours presentation and mortality. Results: There were 398 patients with ATC identified during the study period, of whom 197 (49.5%) presented after hours. Mortality among patients presenting after hours was 43.1%, significantly higher than among those presenting in hours (33.1%; P = 0.04). Following adjustment for possible confounding variables of age, presenting Glasgow Coma Scale score, urgent surgery or angiography and initial base deficit, after-hours presentation was significantly associated with higher mortality at hospital discharge (adjusted odds ratio, 1.77; 95% CI, 1.10-2.87). Conclusion: The after-hours model of care was associated with worse outcomes among some of the most critically ill trauma patients. Standardising patient reception at major trauma centres to ensure a consistent level of care across all hours of the day may improve outcomes among patients who have had a severe injury.

Clonidine may have beneficial effects in patients undergoing major surgery. We enrolled 156 patients having elective CABG surgery in a double-blind, randomized trial. Patients were randomized to receive either two doses of placebo (Group PP) or clonidine 5 µg/kg (Group CC). Perioperative measurements included haemodynamics, anaesthetic and analgesic drug usage, creatinine clearance, cortisol excretion, recovery times and quality of life (SF-36) after surgery. Overall, there was no significant difference with time to tracheal extubation (median [10-90 centile]): CC 7.1(3.4-18) h vs PP 8.0(4.3-17) h, P=0.70; but there was a higher proportion of patients extubated within four hours: CC 20% vs. PP 8%, P=0.038. Clonidine resulted in a number of significant (P<0.05) haemodynamic changes, particularly pre-CPB: less tachycardia and hypertension, more bradycardia and hypotension. Clonidine was associated with a significant (P<0.05) reduction in anaesthetic drug usage, higher creatinine clearance, lower cortisol excretion and improvement in some aspects of quality of life. This study lends support to consideration of clonidine therapy in patients undergoing CABG surgery.

After agreeing to review this publication, and while awaiting its delivery, I contemplated what I would expect in a book with this title The Anaesthetic Crisis Manual. I envisaged a number of checklists such as pilots have, to ensure they are doing everything they are supposed to when things are not going to plan. They are supposed to know the first few steps and then refer to the manual, readily accessible within the cockpit. When it arrived, I was interested to see that the author, an Australian anaesthetist, is also a qualified pilot. It is a small publication without an introduction, references or index. The first page lists major anaesthetic crises, subdivided into cardiovascular, respiratory, obstetric and miscellaneous. Each event leads to a tab which leads instantly to a management checklist. The recommended steps are in ten words or less. Most are things one would expect a qualified anaesthetist to do without a prompt (I did not notice any 'hot off the press' management strategies). However, even experienced staff have been known to miss a vital step during crisis management. Opposite each checklist is a bit more detail including drug doses, which can also be easy to forget when the heat is on. The inside back cover has space for emergency telephone numbers and a tab to enable it to hang on an anaesthetic machine or trolley. It feels as if it is made to enable blood and other fluids to be easily wiped off. Many trainees and some departments probably have similar self-produced notes. For trainees, it does present a succinct checklist, which may be handy for revision but is probably lacking some of the detail a trainee may wish to know. But this is not what it is written for. What sets this book apart is the way the information is presented: clearly and concisely, in a format that is conducive to use during a crisis in any anaesthetising location. I am unaware of any other similar publications. I could see this book living on the side of the machine or in the briefcase of those whose practice involves a number of different locations.

Veterinary care has continued to advance by implementing more of the equipment and techniques that are commonly used in human medicine. This includes the placement of arterial catheters and pulmonary artery catheters and continuous monitoring of arterial pressure, central venous pressure, and pulmonary artery pressure. This article describes the technique for placement of appropriate catheters, the equipment that is needed, and the waveforms that are obtained when measuring direct arterial pressures, central venous pressures, and pulmonary arterial pressures. Copyright 0 2000 by W.B. Saunders Company M onitoring of the cardiovascular system is essential when caring for critical patients. Methods to monitor the cardiovascular system include electrocardiogram (ECG) and measurement of arterial blood pressure, central venous pressure (CVP), pulmonary artery pressure (PAP), and pulmonary artery occlusion pressure (PAOP). The use of an ECG and indirect measurement of blood pressure has become relatively common in veterinary medicine, whereas direct arterial blood pressure (DABP) measurement and CVP monitoring are not widely performed. Direct arterial pressure monitoring is much more accurate than noninvasive methods in both awake and anesthetized veterinary patients, especially critically ill patients, and allows for continuous measurements instead of intermittent values that are obtained with noninvasive meth-From the

Curt Schimmelbusch was born in Germany in 1860 and died only 35 years later leaving his name forever imprinted on the minds of anaesthetists-the Schimmelbusch mask being one piece of historical anaesthetic equipment most anaesthetists would recognise. Schimmelbusch was a surgeon in Berlin and was operating during a time of great change in surgery. In 1880 the germ theory of wound infection was finally proven, mainly due to the studies of Koch. A visitor to Berlin in 1882 asked the chief surgeon, Ernst Bergmann, what was new in surgery and was told' 'Today we wash our hands before operation"! Koch demonstrated that steam was a more effective sterilizer than carbolic acid and that it was also sporicidal. Thermal methods of sterilization were then adapted by Kiel who applied them to operating gowns and other surgical equipment. Schimmelbusch was a great believer in thermal sterilization and refined these methods to make them more practical. He and the French scientist, Terrier, created separately, but almost simultaneously, the steam sterilizer. Surgical instruments without wooden handles were also developed around this time by the German surgeon Neuber making thermal sterilization of instruments a more practical consideration. BIBLIOGRAPHY Duncum BM. The Development of Inhalational Anaesthesia. Oxford University Press. Bryn-Thomas K. The Development of Anaesthetic Apparatus.

was born in Bathgate, Scotland on 7th June 1811. He qualified in medicine in 1830 at the age of nineteen and went on to specialize in obstetrics. He was appointed Professor of Midwifery in Edinburgh at the age of thirty, an extremely prestigious appointment for one so young. It is rumoured that he added "Young" to his name at this time although there is no conclusive evidence to support this. Undoubtedly he was the best candidate for the job. In his job application he submitted 200 pages of testimonials and references, including a 60 page appendix in which his 700 museum specimens were catalogued. The only obstacle that lay in the way of his appointment was the fact that the Edinburgh City Council required a married man for the job. He solved this by marrying the day before the election. Simpson was an obstetrician and probably seldom performed operative surgery. When he heard about the use of ether for anaesthesia he was quick to apply it to his obstetric practice. Pleased with the concept of inhalational anaesthesia, but not completely happy with ether, he set about finding another agent. His research methods were simple, if a little foolish. He inhaled a vast array of substances including acetone, nitric ether, benzin, iodoform vapour, chloride of hydrocarbon, aldehyde and bisulphuret of carbon, all without success. Eventually David Waldie, a Liverpool chemist, suggested chloroform, or perchloride of formyle as it was known. On the 4th November 1847, Simpson, his assistants, Matthews Duncan and George Keith and his niece, Miss Petrie, chloroformed themselves at the dining room table. The dinner party was evidently a great success. Six days later, on November 10, Simpson presented a paper to the Medico-Chirurgical Society of Scotland. "I have found, however, one infinitely more efficacious than any of the others, I am enabled to speak most confidently of its superior anaesthetic properties, having now tried it upon upwards of thirty individuals." He recommended ".. . one or two teaspoons of the chloroform should be placed upon the hollow of the handkerchief, and immediately held to the face of the patient. Generally a snoring sleep speedily supervenes, and when it does so, it is the perfect test of the superinduction of complete insensibility." He admitted that he had not used it at that time for "any