Crisis management during anaesthesia: bronchospasm

© 2005 BMJ Publishing Group Ltd.BACKGROUND: Bronchospasm in association with anaesthesia may appear as an entity in its own right or be a component of another problem such as anaphylaxis. It may present with expiratory wheeze, prolonged exhalation or, in severe cases, complete silence on auscultation. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for bronchospasm, in the diagnosis and management of bronchospasm occurring in association with anaesthesia. METHODS: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by anaesthetists involved. RESULTS: There were 103 relevant incidents among the first 4000 AIMS reports, 22 of which were associated with allergy or anaphylaxis. Common presenting signs, in addition to wheeze, were decreased pulmonary compliance and falling oxygen saturation. Of the non-allergy/anaphylaxis related incidents, 80% occurred during induction or maintenance of anaesthesia. Of these, the principal causes of bronchospasm were airway irritation (35%), problems with the endotracheal tube (23%), and aspiration of gastric contents (14%). It was considered that, properly used, the structured approach recommended would have led to earlier recognition and/or better management of the problem in 10% of cases, and would not have harmed any patient had it been applied in all of them. CONCLUSION: Bronchospasm may present in a variety of ways and may be associated with other life threatening conditions. Although most cases are handled appropriately by the attending anaesthetist, the use of a structured approach to its diagnosis and management would lead to earlier recognition and/or better management in 10% of cases.R N Westhorpe, G L Ludbrook, S C Help

Cerebrovascular carbon dioxide reactivity in sheep: Effect of propofol or isoflurane anaesthesia

Publisher's copy made available with the permission of the publisher © Australian Society of AnaesthetistsPropofol and isoflurane are commonly used in neuroanaesthesia. Some published data suggest that the use of these agents is associated with impaired cerebral blood flow/carbon dioxide (CO₂) reactivity. Cerebrovascular CO₂ reactivity was therefore measured in three cohorts of adult merino sheep: awake (n=6), anaesthetized with steady-state propofol (15 mg/min; n=6) and anaesthetized with 2% isoflurane (n=6). Changes in cerebral blood flow were measured continuously from changes in velocities of blood in the sagittal sinus via a Doppler probe. Alterations in the partial pressure of carbon dioxide in arterial blood (PaCO₂) over the range 18-63 mmHg were achieved by altering either the inspired CO₂ concentration or the rate of mechanical ventilation. Cerebral blood flow/CO₂ relationships were determined by linear regression analysis, with changes in cerebral blood flow expressed as a percentage of the value for a PaCO₂ of 35 mmHg. Propofol decreased cerebral blood flow by 55% relative to pre-anaesthesia values (P=0.0001), while isoflurane did not significantly alter cerebral blood flow (88.45% of baseline, P=0.39). Significant linear relationships between cerebral blood flow and CO₂ tension were determined in all individual studies (r2 ranged from 0.72 to 0.99). The slopes of the lines were highly variable between individuals for the awake cohort (mean 4.73, 1.42-7.12, 95% CI). The slopes for the propofol (mean 2.67, 2.06-3.28, 95% CI) and isoflurane (mean 2.82, 2.19-3.45, 95% CI) cohorts were more predictable. However, there was no significant difference between these anaesthetic agents with respect to the CO₂ reactivity of cerebral blood flow.J. A. Myburgh, R. N. Upton, G. L. Ludbrook, A. Martinez, C. Granthttp://www.aaic.net.au/Article.asp?D=200137

Determining the Surface-To-Bulk Progression in the Normal-State Electronic Structure of Sr2RuO4 by Angle-Resolved Photoemission and Density Functional Theory

In search of the potential realization of novel normal-state phases on the surface of Sr2RuO4 - those stemming from either topological bulk properties or the interplay between spin-orbit coupling (SO) and the broken symmetry of the surface - we revisit the electronic structure of the top-most layers by ARPES with improved data quality as well as ab-initio LDA slab calculations. We find that the current model of a single surface layer (\surd2x\surd2)R45{\deg} reconstruction does not explain all detected features. The observed depth-dependent signal degradation, together with the close quantitative agreement with LDA+SO slab calculations based on the LEED-determined surface crystal structure, reveal that (at a minimum) the sub-surface layer also undergoes a similar although weaker reconstruction. This points to a surface-to-bulk progression of the electronic states driven by structural instabilities, with no evidence for Dirac and Rashba-type states or surface magnetism.Comment: 4 pages, 4 figures, 1 table. Further information and PDF available at: http://www.phas.ubc.ca/~quantmat/ARPES/PUBLICATIONS/articles.htm

Na2IrO3 as a spin-orbit-assisted antiferromagnetic insulator with a 340 meV gap

We study Na2IrO3 by ARPES, optics, and band structure calculations in the local-density approximation (LDA). The weak dispersion of the Ir 5d-t2g manifold highlights the importance of structural distortions and spin-orbit coupling (SO) in driving the system closer to a Mott transition. We detect an insulating gap {\Delta}_gap = 340 meV which, at variance with a Slater-type description, is already open at 300 K and does not show significant temperature dependence even across T_N ~ 15 K. An LDA analysis with the inclusion of SO and Coulomb repulsion U reveals that, while the prodromes of an underlying insulating state are already found in LDA+SO, the correct gap magnitude can only be reproduced by LDA+SO+U, with U = 3 eV. This establishes Na2IrO3 as a novel type of Mott-like correlated insulator in which Coulomb and relativistic effects have to be treated on an equal footing.Comment: Accepted in Physical Review Letters. Auxiliary and related material can be found at: http://www.phas.ubc.ca/~quantmat/ARPES/PUBLICATIONS/articles.htm

Rashba spin-splitting control at the surface of the topological insulator Bi2Se3

The electronic structure of Bi2Se3 is studied by angle-resolved photoemission and density functional theory. We show that the instability of the surface electronic properties, observed even in ultra-high-vacuum conditions, can be overcome via in-situ potassium deposition. In addition to accurately setting the carrier concentration, new Rashba-like spin-polarized states are induced, with a tunable, reversible, and highly stable spin splitting. Ab-initio slab calculations reveal that these Rashba state are derived from the 5QL quantum-well states. While the K-induced potential gradient enhances the spin splitting, this might be already present for pristine surfaces due to the symmetry breaking of the vacuum-solid interface.Comment: A high-resolution version can be found at http://www.physics.ubc.ca/~quantmat/ARPES/PUBLICATIONS/Articles/BiSe_K.pd

Interim analyses of data as they accumulate in laboratory experimentation

BACKGROUND: Techniques for interim analysis, the statistical analysis of results while they are still accumulating, are highly-developed in the setting of clinical trials. But in the setting of laboratory experiments such analyses are usually conducted secretly and with no provisions for the necessary adjustments of the Type I error-rate. DISCUSSION: Laboratory researchers, from ignorance or by design, often analyse their results before the final number of experimental units (humans, animals, tissues or cells) has been reached. If this is done in an uncontrolled fashion, the pejorative term 'peeking' has been applied. A statistical penalty must be exacted. This is because if enough interim analyses are conducted, and if the outcome of the trial is on the borderline between 'significant' and 'not significant', ultimately one of the analyses will result in the magical P = 0.05. I suggest that Armitage's technique of matched-pairs sequential analysis should be considered. The conditions for using this technique are ideal: almost unlimited opportunity for matched pairing, and a short time between commencement of a study and its completion. Both the Type I and Type II error-rates are controlled. And the maximum number of pairs necessary to achieve an outcome, whether P = 0.05 or P > 0.05, can be estimated in advance. SUMMARY: Laboratory investigators, if they are to be honest, must adjust the critical value of P if they analyse their data repeatedly. I suggest they should consider employing matched-pairs sequential analysis in designing their experiments

Services just for men? Insights from a national study of the well men services pilots.

Men continue to have a lower life expectancy in most countries compared to women. Explanations of this gendered health inequality tend to focus on male risk taking, unhealthy lifestyle choices and resistance to seeking help from health services. In the period 2005-2008 the Scottish Government funded a nationwide community health promotion programme aimed at improving men's health, called Well Men Service Pilots (henceforth WMS)

Pharmacokinetics of tramadol after subcutaneous administration in a critically ill population and in a healthy cohort

BACKGROUND: Tramadol is an atypical centrally acting analgesic agent available as both oral and parenteral preparations. For patients who are unable to take tramadol orally, the subcutaneous route of administration offers an easy alternative to intravenous or intramuscular routes. This study aimed to characterise the absorption pharmacokinetics of a single subcutaneous dose of tramadol in severely ill patients and in healthy subjects. METHODS/DESIGN: Blood samples (5 ml) taken at intervals from 2 minutes to 24 hours after a subcutaneous dose of tramadol (50 mg) in 15 patients (13 male, two female) and eight healthy male subjects were assayed using high performance liquid chromatography. Pharmacokinetic parameters were derived using a non-compartmental approach. RESULTS: There were no statistically significant differences between the two groups in the following parameters (mean ± SD): maximum venous concentration 0.44 ± 0.18 (patients) vs. 0.47 ± 0.13 (healthy volunteers) mcg/ml (p = 0.67); area under the plasma concentration-time curve 177 ± 109 (patients) vs. 175 ± 75 (healthy volunteers) mcg/ml*min (p = 0.96); time to maximum venous concentration 23.3 ± 2 (patients) vs. 20.6 ± 18.8 (healthy volunteers) minutes (p = 0.73) and mean residence time 463 ± 233 (patients) vs. 466 ± 224 (healthy volunteers) minutes (p = 0.97). CONCLUSIONS: The similar time to maximum venous concentration and mean residence time suggest similar absorption rates between the two groups. These results indicate that the same dosing regimens for subcutaneous tramadol administration may therefore be used in both healthy subjects and severely ill patients. TRIAL REGISTRATION: ACTRN12611001018909.Neil M Dooney, Krishnaswamy Sundararajan, Tharapriya Ramkumar, Andrew A Somogyi, Richard N Upton, Jennifer Ong, Stephanie N O, Connor, Marianne J Chapman and Guy L Ludbroo

Definition of ambulatory blood pressure targets for diagnosis and treatment of hypertension in relation to clinic blood pressure: prospective cohort study

Background Twenty-four hour ambulatory blood pressure thresholds have been defined for the diagnosis of mild hypertension but not for its treatment or for other blood pressure thresholds used in the diagnosis of moderate to severe hypertension. We aimed to derive age and sex related ambulatory blood pressure equivalents to clinic blood pressure thresholds for diagnosis and treatment of hypertension

Small-cell lung cancer in England: trends in survival and chemotherapy using the National Lung Cancer Audit

Background: The purpose of this study was to identify trends in survival and chemotherapy use for individuals with smallcell lung cancer (SCLC) in England using the National Lung Cancer Audit (NLCA). Methods: We used data from the NLCA database to identify people with histologically proven SCLC from 2004–2011. We calculated the median survival by stage and assessed whether patient characteristics changed over time. We also assessed whether the proportion of patients with records of chemotherapy and/or radiotherapy changed over time. Results: 18,513 patients were diagnosed with SCLC in our cohort. The median survival was 6 months for all patients, 1 year for those with limited stage and 4 months for extensive stage. 69% received chemotherapy and this proportion changed very slightly over time (test for trends p = 0.055). Age and performance status of patients remained stable over the study period, but the proportion of patients staged increased (p-value,0.001), mainly because of improved data completeness. There has been an increase in the proportion of patients that had a record of receiving both chemotherapy and radiotherapy each year (from 19% to 40% in limited and from 9% to 21% in extensive stage from 2004 to 2011). Patients who received chemotherapy with radiotherapy had better survival compared with any other treatment (HR 0.24, 95% CI 0.23–0.25). Conclusion: Since 2004, when the NLCA was established, the proportion of patients with SCLC having chemotherapy has remained static. We have found an upward trend in the proportion of patients receiving both chemotherapy and radiotherapy which corresponded to a better survival in this group, but as it only applied for a small proportion of patients, it was not enough to change the overall survival