Anaesthesia and intensive care
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Anaesth Intensive Care · Oct 2003
Randomized Controlled Trial Comparative Study Clinical TrialEpidural catheter migration: a comparison of tunnelling against a new technique of catheter fixation.
We investigated the efficacy of a new technique of epidural catheter fixation that relies on a strip of adhesive foam transfixed by a securing suture. We compared this technique to a tunnelled technique in a prospective, randomized trial (n = 25 in each group). Epidural catheter depth was recorded at the time of insertion and at the time of removal. ⋯ Clinically significant movement was noted in eight patients (32%) in the tunnelled group and seven patients (28%) in the sutured group (P = 0.75). Movement of the epidural catheter did not correlate with analgesic failure. The sutured technique provided similar protection against migration to tunnelling but any potential advantages were offset by concerns about a significantly higher incidence of erythema around the catheter exist site in the sutured group (1 vs 6 patients, P = 0.04).
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The ability of intensive care to replace or support vital organ function has resulted in some patients surviving for long periods of time without improvement or a terminal event. In patients with no realistic chance of survival, decisions to withdraw or withhold life-sustaining therapies are commonly made. Withdrawal of life support at the patient's request is lawful at common law and, in some states of Australia, by legal statute. ⋯ However much weight is frequently placed on the wishes of the family. Disagreements between family and clinicians over decisions to withdraw therapy are unusual and generally resolve over time. However if disagreement persists, it may be advisable to apply to the courts for a declaratory judgement, given the tenuous legal basis of withdrawal of life-sustaining therapy in Australia and the uncertainty over the courts' view of the role of the patient's family in the decision-making process.
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Anaesth Intensive Care · Oct 2003
Withholding and withdrawal of therapy in patients with acute renal injury: a retrospective cohort study.
The incidence of withholding and withdrawal of therapy in the setting of multi-organ failure in critically ill patients has increased. Epidemiological data on the decision-making process of withholding or withdrawal of therapy from Australian and New Zealand intensive care units is sparse. We examined the clinical and electronic records of 179 consecutive patients, admitted to the ICU between 1st January 2000 and 31st December 2001, who had acute renal injury. ⋯ This was likely to be due to an older age of our cohort, rapid progressive nature of the acute disease, a different clinical approach to treating critically ill elderly patients, or a combination of these factors. This pattern of practice was quite different from those reported from ICUs in other parts of the world. A prospective multi-centre observational study will clarify the pattern of practice in this important area of intensive care practice in Australasia.
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Anaesth Intensive Care · Oct 2003
Case ReportsFailed extubation of a double-lumen tube requiring a cricoid split.
Following a five-hour procedure, it was not possible to remove a double-lumen endobronchial tube that had been placed to facilitate the removal of a massive spleen from a 45-year-old female. The tube had been passed easily at the start of surgery, but was firmly stuck at the level of the cricoid at the end of surgery. Surgical removal of the tube by a cricoid split was required 48 hours later. Consideration of previous airway manipulations, careful choice of airway devices and regular checks of airway patency around tracheal tubes during lengthy procedures may prevent similar events in the future.
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Anaesth Intensive Care · Oct 2003
Case ReportsInadvertent subdural spread complicating cervical epidural steroid injection with local anaesthetic agent.
Although cervical epidural steroid injection with local anaesthetic is considered a safe technique and widely practiced, complications may occur. We report a patient experiencing unexpected delayed high block, moderate hypotension and unconsciousness eight to ten minutes after an apparently normal cervical epidural steroid injection. ⋯ Anatomical peculiarities of the epidural and subdural space in the cervical region increase the risk of subdural spread during cervical epidural injection. Fluoroscopic guidance is important during cervical epidural injection to increase certainty of correct needle placement, thus minimizing the risk of complications.