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Biomedical subjects

M T Kluger

Publications and source records attributed to M T Kluger.

At least 19 recordsLinked to original sources
PubMed2000

The relationship between change in blood pressure, blood pressure and time.

Physiological homeostatic mechanisms and interventions by anaesthetists attempt to moderate excessive change in many biological variables during anaesthesia. These mechanisms may have fast or slow response times. This study describes how mean arterial blood pressure changes with time and how the change is dependent upon the pre-existing blood pressure. The results demonstrate the 'regression towards the mean' concept; low arterial blood pressures increase and high pressures decrease. The data are the result of all interactions and have been used to produce an 'envelope' into which 80% of all changes fall. Alarm systems using this envelope could warn of excessive changes that occur within short time intervals.

Adult↗
PubMed2000

Inadequate pre-operative evaluation and preparation: a review of 197 reports from the Australian incident monitoring study.

The Australian Incident Monitoring Study database was examined for incidents involving inadequate pre-operative patient preparation and/or evaluation. Of 6271 reports, 727 had appropriate keywords, of which 197 (3.1%) were used for subsequent analysis. All surgical categories were represented. In 10% of reports the patient was not reviewed pre-operatively by an anaesthetist, whilst in 23% the anaesthetist involved in the operating theatre had not performed the pre-operative assessment. Death followed in seven cases, major morbidity in 23 cases, admission to a high-dependency unit or intensive care unit in 17 cases, and surgery was cancelled in nine cases. Poor airway assessment, communication problems and inadequate evaluation were the most common contributing factors. Respondents indicated that the incident was preventable in 57% of cases. Proposed corrective strategies include improved communication, quality assurance activities, development of protocols and additional training. A structured assessment of the airway, along with improvements in information exchange, patient assessment, and use of clearly defined patient management plans and pathways would prevent most of the incidents reported.

Anesthesiology↗
PubMed2000

Erythromycin improves gastric emptying in critically ill patients intolerant of nasogastric feeding.

OBJECTIVE: To evaluate the effect of intravenous erythromycin on gastric emptying and the success of enteral feeding in mechanically ventilated, critically ill patients with large volume gastric aspirates. DESIGN: Prospective, double-blind, randomized, and placebo-controlled trial. SETTING: General intensive care unit in a university hospital. PATIENTS: Twenty critically ill, mechanically ventilated patients intolerant of nasogastric feeding (indicated by a residual gastric volume of > or =250 mL during feed administration at > or =40 mL/hr). INTERVENTIONS: After a gastric aspirate of > or =250 mL, which was discarded, the enteral feeding was continued at the previous rate for 3 hrs. Intravenous erythromycin (200 mg) or placebo was then administered over 20 mins. The residual gastric contents were again aspirated and the volume was recorded 1 hr after the infusion began. MEASUREMENTS AND MAIN RESULTS: Gastric emptying was calculated as volume of feed infused into the stomach over 4 hrs minus the residual volume aspirated. Mean gastric emptying was 139+/-37 (+/-SEM) mL after erythromycin and -2+/-46 mL after placebo (p = .027). Nasogastric feeding was successful in nine of ten patients treated with erythromycin and five of ten who received placebo 1 hr after infusion (chi-square p = .05). CONCLUSION: In critically ill patients who have large volumes of gastric aspirates indicating a failure to tolerate nasogastric feeding, a single small dose of intravenous erythromycin allows continuation of feed in the short term.

APACHE↗
PubMed2000

Effect of bolus dose of remifentanil on haemodynamic response to tracheal intubation.

A randomized placebo-controlled double-blinded study was conducted in 40 ASA 1 and 2 patients to determine the dose response of remifentanil in attenuating the haemodynamic response to tracheal intubation. Patients were allocated to one of four groups: placebo, remifentanil 1 microgram.kg-1, remifentanil 2 micrograms.kg-1 and remifentanil 4 micrograms.kg-1. A propofol target-controlled infusion was started at 4 micrograms.ml-1 and incrementally titrated to loss of verbal contact. Muscle relaxation was provided by cisatracurium. The study drug was given three minutes later over 30 seconds, and 90 seconds later the patient's trachea was intubated under direct laryngoscopy. Baseline noninvasive blood pressure and heart rate recordings were made prior to starting target-controlled infusion, then at one-minute intervals after loss of verbal contact for the duration of the study. Demographic data and target-controlled infusion rate at intubation was similar for the groups. Following intubation, heart rate increased by 15% in the placebo group, 10% in 1 microgram.kg-1 group, with no changes in 2 micrograms.kg-1 and 4 micrograms.kg-1 groups. Systolic blood pressure following intubation increased by 30% in the placebo group, 10% in the 1 microgram.kg-1 group and remained unchanged in the 2 micrograms.kg-1 and 4 micrograms.kg-1 groups. Remifentanil 1 microgram.kg-1 attenuated the rise in heart rate and systolic blood pressure. Remifentanil 2 micrograms.kg-1 blocked the haemodynamic response completely: no further benefit was shown from increasing the dose to 4 micrograms.kg-1.

Adult↗
PubMed1999

Aspiration during anaesthesia: a review of 133 cases from the Australian Anaesthetic Incident Monitoring Study (AIMS).

Two-hundred and forty incidents of vomiting/regurgitation and aspiration were reported to the Anaesthetic Incident Monitoring Study database consisting of 5000 reports. Of these, 133 cases of aspiration were recorded. Passive regurgitation occurred three times more commonly than active vomiting. Aspiration was reported twice as often in elective compared with emergency surgery, with 56% of incidents taking place during induction of anaesthesia. Anti-aspiration prophylaxis was prescribed in 14% of patients who subsequently aspirated; however, the majority of cases had at least one predisposing factor for regurgitation, vomiting or aspiration evident peri-operatively. While a major immediate physiological disturbance was common, long-term morbidity was not. Death ensued in five cases, all of whom had significant co-morbidities. Factors reported as contributing to the incident included error of judgement and fault of technique, while clinical experience and anaesthetic assistance tended to minimise the incident. Aspiration remains an important anaesthetic-related morbidity. The application of simple guidelines may have prevented the incident in 60% of all cases of aspiration. Ensuring airway security may be as important as chemoprophylaxis in its prevention.

Adolescent↗
PubMed1999

Personality traits of anaesthetists and physicians: an evaluation using the Cloninger Temperament and Character Inventory (TCI-125).

The personality profiles of Specialist Anaesthetists, Trainee Anaesthetists and Specialist Physicians were examined using Cloninger's Temperament and Character Inventory. These were compared with validated Community Sample 'average values' and a historical Norwegian Physician sample. Completed forms were returned from 364 doctors (Specialist Anaesthetists 222, Trainee Anaesthetists 75, Physicians 67), an overall response rate of 71%. Specialist Anaesthetists were more Cooperative, Harm Avoidant and Self-Directed than the Community Sample but less Reward Dependent, Novelty Seeking and Persistent than the Community Sample. Physicians were more Cooperative than their Specialist Anaesthetist colleagues, but both more so than were the general population. Trainee anaesthetists appear to be more Novelty Seeking and Reward Dependent than the Specialist Anaesthetists, this factor being predominately age related. Extreme/Mild personality traits were identified in 33% of Specialists, 41% of Trainees and 33% of Physicians, whilst personality disorders were found at the expected rates (Specialist Anaesthetists 9%, Trainee Anaesthetists 10%, Physicians 2%). Personality assessment has implications for recruitment, crisis management and professional development within anaesthesia.

Adult↗
PubMed1999

Anaesthetic assistants: their role in the development and resolution of anaesthetic incidents.

Trained anaesthetic assistants are considered essential for the safe conduct of anaesthesia. Data from 5837 AIMS (Anaesthetic Incident Monitoring Study) reports were evaluated for issues concerning anaesthetic assistants in the generation and resolution of anaesthetic incidents. "Inadequate assistance" as a contributing factor was identified in 187 reports, whilst "skilled assistance" which minimized the incident was present in 808 cases. One hundred and seventy-two reports specifically commented on anaesthetic assistants in the narrative section of the AIMS form. All surgical specialties were represented. In 147 of these reports the assistant actually contributed to or failed to assist with the incident. Although the majority of outcomes from the reports were uneventful, prolonged stay, awareness and ICU admission did ensue in a small number of cases. The most common incidents were related to problems with equipment, communication and inadequate staffing levels (number and/or skill mix). Results from this study have implications for anaesthetic assistant staffing levels and the orientation of course content.

Anesthesia↗
PubMed1999

Personality profiles of Australian anaesthetists.

Identification of personality traits in anaesthetists has potential implications for selection of trainees, assessment of coping strategies during times of stress and may have a role in the analysis of critical incidents. A 24 question postal questionnaire based on the Cattell 16PF inventory was sent to specialist anaesthetists in Australia. One hundred and sixty-seven replies were received (33% response rate). Personality traits did not differ when the anaesthetists were grouped for age, number of years qualified and country of qualification. City practitioners rated themselves more inquisitive than country practitioners did (P = 0.052). Female anaesthetists self-reported they were calm (P = 0.02), patient (P = 0.02) and tolerant (P = 0.02) more often than their male counterparts, whilst more males reported themselves as highly conscientious (P = 0.01). Although some traits were consistent, personality profiles showed significant heterogeneity. Further examination of how personality and coping mechanisms interact may be central to the management of stress and critical incident generation.

Adult↗
PubMed1998

Anti-aspiration prophylaxis in New Zealand: a national survey.

A postal questionnaire was sent on two occasions to specialist anaesthetists within New Zealand. Questions were related to fasting status, anti-aspiration prophylaxis, incidence of aspiration, definition of high risk groups for aspiration pneumonitis, and identification of departmental guidelines. Two-hundred-and-twenty-three replies were received (72% response rate). Most adults, children and infants were fasted for 6 hours for solids, whilst the majority fasted for 2 to 4 hours for liquids. Two-thirds indicated that they would delay emergency surgery (not life/limb threatening) to optimize gastric emptying. Histamine type 2 receptor antagonists, metoclopramide and cricoid pressure were used commonly, more so in the obstetric population compared to non-obstetric surgery. Preinduction nasogastric intubation and suction were used infrequently. Anti-aspiration prophylaxis was deemed important in morbidly obese patients, those in the third trimester of pregnancy and those with a hiatus hernia, whilst diabetes mellitus, sepsis and renal failure were not considered risk factors for aspiration pneumonitis. 71% of respondents had at least one episode of aspiration (range 0-10), with an overall mortality rate of 5%. Half of these cases of aspiration were deemed to be preventable by the respondent.

Adolescent↗
PubMed1998

Trainees' attitudes to research as part of anaesthetic training.

The formal project has been a requirement for the F.A.N.Z.C.A. diploma for the past few years. A questionnaire was sent to all registrars on a formal program asking questions relating to the formal project, perceived advantages, disadvantages, value of formal research teaching methodology and future career intentions. All years of training were represented. Forty-nine of the fifty-six (86%) respondents replied to the survey. Of these 15% felt the formal project had no value, 54% found it possibly useful whilst 31% perceived is as very useful. Advantages of the formal project included appreciation of research skills and the ability to critically appraise research. Disadvantages included lack of dedicated time, space and funding and production of poor quality research. A majority (63%) favoured formal teaching of research methods for the F.A.N.Z.C.A. diploma, which ideally should be taught before the Primary (30%) or in the Provisional Fellowship year (36%). Few respondents indicated a willingness to undertake a major commitment to research in the future (4%) but 46% wanted some contact with research and teaching as part of their normal work practice. A more structured teaching in research methodology, assessment of published work and presentation skills may be more suited to the longterm goals of the majority of clinical anaesthetists.

Anesthesiology↗
PubMed1995

The effect of oral cisapride premedication on fasting gastric volumes.

The aim of this study was to determine whether fasting gastric volumes could be reduced by preoperative administration of cisapride. One hundred and twenty-one patients undergoing elective general anaesthesia were randomly allocated to receive either cisapride 20 mg plus diazepam 10 mg or placebo tablets plus diazepam 10 mg, two hours prior to induction. Immediately following induction blind gastric aspiration was performed using a 16Fr multiorificed orogastric tube. Gastric volume, pH, and cisapride blood concentration were measured at this time. Gastric volumes were significantly smaller in the cisapride group, 20.5 (SD 22.2) ml compared to placebo 28.2 (SD 26.0) ml but there was no significant difference with respect to pH. Some patients in both groups had large gastric volumes despite fasting. No significant adverse effects were noted with cisapride.

Adjuvants, Anesthesia↗
PubMed1993

The effect of fentanyl administered epidurally by patient-controlled analgesia, continuous infusion, or a combined technique of oxyhaemoglobin saturation after abdominal surgery.

The aims of this study were to determine the effect of three different modes of epidural administration of fentanyl on oxyhaemoglobin saturation and pain control. Forty-three patients undergoing elective abdominal surgery were randomly allocated to the following groups: (1) continuous infusion of fentanyl at a rate of 50 micrograms.h-1 with additional epidural boluses (25 micrograms) as required; (2) patient-controlled analgesia using a 25 microgram epidural bolus of fentanyl with a 15 min lock-out period; (3) a combination of patient-controlled analgesia and continuous infusion. Oxyhaemoglobin saturation was measured by continuous computerised pulse oximetry for 48 h after operation together with pain and sedation scores. In the first 24 h after surgery patients in the continuous infusion group spent a significantly greater proportion of time below oxygen saturations of 94% and 85% than those in the other two groups. On day 2 all oxygen saturation measurements were worse than during day 1, but differences between groups were not significant. Those patients receiving patient-controlled analgesia required significantly less fentanyl than patients in either of the other groups (p < 0.05). However, the mean pain and sedation scores did not differ significantly between the three treatment groups. There was no association between total fentanyl dose and oxygen saturation values. Overall, self-administered fentanyl appeared to cause less oxyhaemoglobin desaturation than nurse-administered analgesia without any loss of analgesic effect.

Adolescent↗
PubMed1993

Background infusion with patient-controlled analgesia: effect on postoperative oxyhaemoglobin saturation and pain control.

The aim of this study was to determine whether the addition of a background infusion (BI) to patient-controlled analgesia (PCA) would lead to significantly improved pain control or poorer oxyhaemoglobin saturation (SpO2) after gynaecological surgery. Sixty-two patients were studied for 24 hours postoperatively; pain scores and morphine dose were recorded hourly, SpO2 was recorded every 10 seconds. Administration of the BI resulted in a significant increase in total morphine dose received although there was no difference in the severity of postoperative desaturation between the therapies. Despite the increased morphine dose pain scores also were similar in the two groups. Addition of a BI at 1 mg/hr did not confer any advantage over PCA alone and is not recommended when PCA is used in this patient group.

Adult↗
PubMed1992

Oxyhaemoglobin saturation following elective abdominal surgery in patients receiving continuous intravenous infusion or intramuscular morphine analgesia.

Oxygen saturation was continuously measured using computerised pulse oximetry for 8 h overnight pre-operatively and for the first 24 h postoperatively in 40 patients receiving intermittent intramuscular morphine or continuous infusion of morphine following elective upper abdominal surgery. The proportion of time with an oxygen saturation less than 94% was used as an index of desaturation. Patients receiving continuous infusion analgesia received a larger morphine dose and achieved better analgesia than the intramuscular group. Postoperatively, the duration of desaturation increased 10-fold over pre-operative values, 'intramuscular' patients spending 39.0% (SD, 37.0%) and 'continuous infusion' patients 40.0% (SD, 37.5%) of the time below 94% saturation. Although newer therapies (e.g. epidural analgesia and patient-controlled analgesia) are currently receiving greater attention, the sequelae of these more traditional analgesic techniques warrant further study.

Abdomen↗