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1.
BMJ Mil Health ; 169(2): 122-126, 2023 Apr.
Article in English | MEDLINE | ID: mdl-33087539

ABSTRACT

INTRODUCTION: Care of battle casualties is a central role of military medical practitioners. Historically, certain trauma procedural skills have been learnt through live tissue training. However, faced with opposition from community members and academics, who argue equivalence of non-animal alternatives, this is now being phased out. This study explores Australian military medical practitioners' experiences of and attitudes towards live tissue training. METHOD: We performed a phenomenologically driven qualitative exploration of individuals' experiences of live tissue trauma training. 32 medical officers volunteered for the study. In-depth interviews were conducted with 15 practitioners (60% Army, 20% Air Force, 20% Navy; 33% surgical, 53% critical care, 13% general practice). Qualitative data were subjected to content analysis, with key themes identified using manual and computer-assisted coding. RESULTS: Live tissue training was valued by military medical practitioners, particularly because of the realistic feel of tissues and physiological responsiveness to treatment. Learner-perceived value of live tissue training was higher for complex skills and those requiring delicate tissue handling. 100% of surgeons and critical care doctors regarded live tissue as the only suitable model for learning repair of penetrating cardiac injury. Live tissue training was felt to enhance self-efficacy, particularly for rarely applied skills. Though conscious of the social and ethical context of live tissue training, >90% of participants reported positive emotional responses to live tissue training. CONCLUSION: In contrast to published research, live tissue training was thought by participants to possess characteristics that are not yet replicable using alternative learning aids. The experienced positive values of live tissue training should inform the decision to move towards non-animal alternatives.


Subject(s)
Health Personnel , Surgeons , Humans , Australia , Clinical Competence
2.
Anaesth Intensive Care ; 46(3): 313-320, 2018 May.
Article in English | MEDLINE | ID: mdl-29716490

ABSTRACT

Unnecessary pathology tests performed in intensive care units (ICU) might lead to increased costs of care and potential patient harm due to unnecessary phlebotomy. We hypothesised that a multimodal intervention program could result in a safe and effective reduction in the pathology tests ordered in our ICU. We conducted a single-centre pre- and post-study using multimodal interventions to address commonly ordered routine tests. The study was performed during the same six month period (August to February) over three years: 2012 to 2013 (pre-intervention), 2013 to 2014 (intervention) and 2014 to 2015 (post-intervention). Interventions consisted of staff education, designing new pathology forms, consultant-led pathology test ordering and intensive monitoring for a six-month period. The results of the study showed that there was a net savings of over A$213,000 in the intervention period and A$175,000 in the post-intervention period compared to the pre-intervention period. There was a 28% reduction in the tests performed in the intervention period (P <0.0001 compared to pre-intervention period) and 26% in the post-intervention period (P <0.0001 compared to pre-intervention period). There were no ICU or hospital mortality differences between the groups. There were no significant haemoglobin differences between the groups. A multimodal intervention safely reduced pathology test ordering in the ICU, resulting in substantial cost savings.


Subject(s)
Critical Care/methods , Diagnostic Tests, Routine/statistics & numerical data , Hematologic Tests/statistics & numerical data , Quality Improvement/statistics & numerical data , Critical Care/economics , Diagnostic Tests, Routine/economics , Hematologic Tests/economics , Humans , Intensive Care Units/statistics & numerical data , Queensland
3.
J R Army Med Corps ; 164(3): 142-149, 2018 Jul.
Article in English | MEDLINE | ID: mdl-29331949

ABSTRACT

INTRODUCTION: Bibliometric tools can be used to identify the authors, topics and research institutions that have made the greatest impact in a field of medicine. The aim of this research was to analyse military trauma publications over the last 16 years of armed conflict in order to highlight the most important lessons that have translated into civilian practice and military doctrine as well as identify emerging areas of importance. METHODS: A systematic search of research published between January 2000 and December 2016 was conducted using the Thompson Reuters Web of Science database. Both primary evidence and review publications were included. Results were categorised according to relevance and topic and the 30 most cited publications were reviewed in full. The h-index, impact factors, citation counts and citation analysis were used to evaluate results. RESULTS: A plateau in the number of annual publications on military trauma was found, as was a shift away from publications on wound and mortality epidemiology to publications on traumatic brain injury (TBI), neurosurgery or blast injury to the head. Extensive collaboration networks exist between highly contributing authors and institutions, but less collaboration between authors from different countries. The USA produced the majority of recent publications, followed by the UK, Germany and Israel. CONCLUSIONS: In recent years, the number of publications on TBI, neurosurgery or blast injury to the head has increased. It is likely that the lessons of recent conflicts will continue to influence civilian medical practice, particularly regarding the long-term effects of blast-related TBI.


Subject(s)
Bibliometrics , Military Medicine , Publications , Wounds and Injuries , Humans
4.
Anaesth Intensive Care ; 45(6): 663-675, 2017 11.
Article in English | MEDLINE | ID: mdl-29137575

ABSTRACT

Uncertainty surrounds the optimal approach to feeding the critically ill, with increasing interest in the concept of intentional underfeeding to reduce metabolic stress while maintaining gut integrity. Conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, this systematic review evaluates clinical outcomes reported in studies comparing hypocaloric normonitrogenous or trophic feeding (collectively 'intentional underfeeding') targeted full energy feeding administered via enteral nutrition to adult critically ill patients. Electronic databases including PubMed, CINAHL, EMBASE and CENTRAL were searched up to September 2017 for trials evaluating intentional underfeeding versus targeted energy feeding interventions on clinical outcomes (mortality, length of stay, duration of ventilation, infective complications, feeding intolerance and glycaemic control) among critically ill adult patients. Bias of included studies was assessed using the Cochrane risk of bias tool. Of the 595 articles identified, seven studies (six randomised controlled trials, one non-randomised trial) met the inclusion criteria, representing 2,684 patients (hypocaloric normonitrogenous n=668; trophic n=681; full energy feeding n=1335). Across the studies, there was considerable heterogeneity in study methodology, population, feeding strategy and outcomes and their timepoints. We observed no evidence that intentional underfeeding, when compared to targeting full energy feeding, reduced mortality or duration of ventilation or length of stay. However, limited trial evidence is available on the impact of intentional underfeeding on post-discharge functional and quality of life outcomes.


Subject(s)
Critical Illness/mortality , Energy Intake , Enteral Nutrition , Adult , Humans , Infections/mortality , Length of Stay , Respiration, Artificial/mortality
5.
Intensive Care Med ; 41(9): 1549-60, 2015 Sep.
Article in English | MEDLINE | ID: mdl-25952825

ABSTRACT

PURPOSE: To determine whether early goal-directed therapy (EGDT) reduces mortality compared with other resuscitation strategies for patients presenting to the emergency department (ED) with septic shock. METHODS: Using a search strategy of PubMed, EmBase and CENTRAL, we selected all relevant randomised clinical trials published from January 2000 to January 2015. We translated non-English papers and contacted authors as necessary. Our primary analysis generated a pooled odds ratio (OR) from a fixed-effect model. Sensitivity analyses explored the effect of including non-ED studies, adjusting for study quality, and conducting a random-effects model. Secondary outcomes included organ support and hospital and ICU length of stay. RESULTS: From 2395 initially eligible abstracts, five randomised clinical trials (n = 4735 patients) met all criteria and generally scored high for quality except for lack of blinding. There was no effect on the primary mortality outcome (EGDT: 23.2% [495/2134] versus control: 22.4% [582/2601]; pooled OR 1.01 [95% CI 0.88-1.16], P = 0.9, with heterogeneity [I(2) = 57%; P = 0.055]). The pooled estimate of 90-day mortality from the three recent multicentre studies (n = 4063) also showed no difference [pooled OR 0.99 (95% CI 0.86-1.15), P = 0.93] with no heterogeneity (I(2) = 0.0%; P = 0.97). EGDT increased vasopressor use (OR 1.25 [95% CI 1.10-1.41]; P < 0.001) and ICU admission [OR 2.19 (95% CI 1.82-2.65); P < 0.001]. Including six non-ED randomised trials increased heterogeneity (I(2) = 71%; P < 0.001) but did not change overall results [pooled OR 0.94 (95% CI 0.82 to 1.07); P = 0.33]. CONCLUSION: EGDT is not superior to usual care for ED patients with septic shock but is associated with increased utilisation of ICU resources.


Subject(s)
Shock, Septic/therapy , Critical Care/methods , Early Medical Intervention , Goals , Humans , Randomized Controlled Trials as Topic , Shock, Septic/mortality
7.
J R Army Med Corps ; 161(4): 336-40, 2015 Dec.
Article in English | MEDLINE | ID: mdl-25512440

ABSTRACT

The Australian Army recently adopted the British concept of hospital exercise (HOSPEX) as a means of evaluating the capabilities of its deployable NATO Role 2E hospital, the 2nd General Health Battalion. The Australian approach to HOSPEX differs from the original UK model. This article describes the reasons why the Australian Army needed to adopt the HOSPEX concept, how it was adapted to suit local circumstances and how the concept may evolve to meet the needs of the wider Australian Defence Force and our allies.


Subject(s)
Hospitals, Military , Mobile Health Units , Australia , Hospital Units/organization & administration , Humans , United Kingdom
9.
J Crit Care ; 29(3): 471.e11-7, 2014 Jun.
Article in English | MEDLINE | ID: mdl-24508201

ABSTRACT

PURPOSE: Uncontrolled bleeding is the main preventable cause of death in severe trauma patients. Fibrinogen is the first coagulation factor to decrease during trauma-induced coagulopathy, suggesting that pharmacological replacement might assist early hemorrhage control. Several sources of fibrinogen are available; however, fibrinogen concentrate (FC) is not routinely used in trauma settings in most countries. The aim of this review is to summarize the available literature evaluating the use of FC in the management of severe trauma. METHODS: Studies reporting the administration of FC in trauma patients published between January 2000 and April 2013 were identified from MEDLINE and from the Cochrane Library. RESULTS: The systematic review identified 12 articles reporting FC usage in trauma patients: 4 case reports, 7 retrospective studies, and 1 prospective observational study. Three of these were not restricted to trauma patients. CONCLUSIONS: Despite methodological flaws, some of the available studies suggested that FC administration may be associated with a reduced blood product requirement. Randomized trials are warranted to determine whether FC improves outcomes in prehospital management of trauma patients or whether FC is superior to another source of fibrinogen in early hospital management of trauma patients.


Subject(s)
Fibrinogen/therapeutic use , Hemorrhage/therapy , Hemostatics/therapeutic use , Wounds and Injuries/complications , Fibrinogen/adverse effects , Hemorrhage/etiology , Hemostatics/adverse effects , Humans , Observational Studies as Topic , Prospective Studies , Retrospective Studies , Safety
11.
Anaesth Intensive Care ; 41(4): 453-5, 2013 Jul.
Article in English | MEDLINE | ID: mdl-23808501
12.
Anaesth Intensive Care ; 41(1): 10-9, 2013 Jan.
Article in English | MEDLINE | ID: mdl-23362885

ABSTRACT

The development of effective cryopreservation techniques for both red blood cells and platelets, which maintain ex vivo biological activity, in combination with frozen plasma, provides for a unique blood banking strategy. This technology greatly enhances the storage life of these products. The rationale and potential advantages of using cryopreservation techniques for the provision of blood products to remote and military environments have been effectively demonstrated in several conflicts over the last decade. Current haemostatic resuscitation doctrine for the exsanguinating patient supports the use of red blood cells, platelets and frozen plasma early in the resuscitation. We believe an integrated fresh-frozen blood bank inventory could facilitate provision of blood products, not only in the military setting but also in regional Australia, by overcoming many logistic and geographical challenges. The processes involved in production and point of care thawing are sufficiently well developed and achievable to make this technology a viable option. The potential limitations of cryopreservation and subsequent product thawing need to be considered if such a strategy is to be developed. A substantial body of international experience using cryopreserved products in remote settings has already been accrued. This experience provides a template for the possible creation of an Australian integrated fresh-frozen blood bank inventory that could conceivably enhance the care of patients in both regional Australia and in the military setting.


Subject(s)
Blood Preservation/methods , Blood Transfusion/methods , Cryopreservation/methods , Australia , Blood Banking/methods , Blood Component Transfusion/methods , Erythrocyte Transfusion/methods , Hemorrhage/therapy , Humans , Military Medicine/methods , Time Factors
14.
Anaesth Intensive Care ; 39(3): 465-71, 2011 May.
Article in English | MEDLINE | ID: mdl-21675068

ABSTRACT

Inadequate ventilation of intubated patients during transport from the operating theatre to the intensive care unit with attendant hypercarbia may adversely affect haemodynamics. In a retrospective observational study, we assessed the incidence of inadequate ventilation during transport from the operating theatre to the intensive care unit in 99 consecutive cardiac surgery patients admitted to our university tertiary hospital. Demographic, clinical, arterial blood gas and haemodynamic measurements were made on arrival in the intensive care unit after cardiac surgery. The relationships between arterial carbon dioxide tension (P(a)CO2), mean pulmonary artery pressure (MPAP) and other relevant haemodynamic variables were explored. Overall, hypocarbia (P(a)CO2 < 35 mmHg) occurred in 18.2% of patients, while 28.3% of patients had hypercarbia (P(a)CO2 > 45 mmHg). Pulmonary hypertension was common, with nearly half of the cohort having MPAP > or = 25 mmHg and 17.2% > or = 30 mmHg. However there was no association between P(a)CO2 and MPAP (R2 = 0.0076, P = 0.39). Contrary to expectation, neither hypercarbia nor high MPAP were associated with measured adverse outcomes, although this may have been because we studied an insufficient number of patients with extreme values. Associations of higher MPAP, which would be expected to compromise cardiovascular status, included acidaemia, hypoxia and the requirement for noradrenaline. These factors define a group of high-risk patients who should receive particular attention and who should be the focus of future studies.


Subject(s)
Cardiac Surgical Procedures , Respiration, Artificial , Transportation of Patients , Adolescent , Adult , Aged , Blood Pressure , Carbon Dioxide/blood , Child , Cohort Studies , Female , Humans , Male , Middle Aged , Pulmonary Artery/physiopathology , Retrospective Studies
15.
Anaesth Intensive Care ; 39(1): 122-6, 2011 Jan.
Article in English | MEDLINE | ID: mdl-21375102

ABSTRACT

Intensivists frequently prescribe oxygen therapy for critically ill patients, however little is known about how intensivists manage oxygen therapy, or what factors influence their decisions. We surveyed intensivists listed on the Australian and New Zealand Intensive Care Society Clinical Trials Group database to investigate how intensivists report their approach to the monitoring, prescription and management of risks associated with oxygen therapy. The response rate was 60.4% (99/164 intensivists). Overall 81 (83.5%) respondents practised in metropolitan units and 50 (50.5%) had > or =14 years of intensive care unit specialty practice. All respondents reported using pulse oximetry and > 93% reported having access to a blood gas machine within their intensive care unit. Sixty-one percent of respondents (60/98) reported assessing other indices of tissue oxygenation (pH, lactate, MvO2). Twelve respondents (12.8%) believed that oxygen toxicity was a greater threat to lung injury than barotrauma when commencing mechanical ventilation. A significantly (P = 0.016) greater proportion of regional (5/16) than metropolitan (7/70) respondents were concerned that a high FiO2 is a greater threat to the lungs than barotrauma. For a ventilated acute respiratory distress syndrome patient, 36.8% (36/98 respondents) would not allow an SaO2 of < 85% for < or =15 minutes, and 27.6% (27/96 respondents) would not allow an SaO2 < 90% for > 24 hours. Respondents with < or = 14 years of specialty practice were more likely to specify the oxygen delivery device to be used (P = 0.014). Recognising the factors that currently influence oxygen administration decisions is a necessary prelude to the potential conduct of interventional studies, as well as for the development of better guidance for oxygen therapy in critical care.


Subject(s)
Attitude of Health Personnel , Critical Care/statistics & numerical data , Intensive Care Units/statistics & numerical data , Oxygen Inhalation Therapy/statistics & numerical data , Respiratory Distress Syndrome/therapy , Self Report , Australia , Humans , New Zealand , Oxygen Inhalation Therapy/methods , Surveys and Questionnaires
16.
Minerva Anestesiol ; 74(4): 145-8, 2008 Apr.
Article in English | MEDLINE | ID: mdl-18030250

ABSTRACT

Factor VIIa might be a useful treatment for coagulopathy and massive hemorrhage following implantation of a mechanical circulatory assist device, but there is a theoretical risk of device thrombosis. To date this complication has not been reported. We describe the first case of clotting of a left ventricular assist device immediately after administration of factor VIIa.


Subject(s)
Factor VIIa/adverse effects , Heart-Assist Devices , Thrombosis/chemically induced , Aged , Equipment Failure , Humans , Male
17.
Anaesthesia ; 62(4): 364-73, 2007 Apr.
Article in English | MEDLINE | ID: mdl-17381573

ABSTRACT

The first part of this two-part review discussed the indications for various types of epicardial pacing systems and an overview of the routine care of a pacemaker-dependent patient. Dual chamber temporary pulse generators now feature many of the refinements developed initially for use in permanent pacemakers. Few of these are utilised in the immediate postoperative period, often solely due to lack of familiarity with all but basic functions. The second part of the review deals with the selection of pacing modes. Troubleshooting real and apparent pacemaker malfunctions, including manual adjustment of parameters such as the AV interval, post atrial refractory period and upper rate limit, to avoid over- and undersensing, cross-talk and pacemaker-mediated tachycardia will also be addressed.


Subject(s)
Cardiac Pacing, Artificial/methods , Cardiac Surgical Procedures , Postoperative Care/methods , Arrhythmias, Cardiac/therapy , Equipment Failure , Humans , Pacemaker, Artificial , Postoperative Complications/therapy
18.
Anaesthesia ; 62(3): 264-71, 2007 Mar.
Article in English | MEDLINE | ID: mdl-17300304

ABSTRACT

Epicardial wires allow temporary pacing after cardiac surgery. Pacing is often the best, and sometimes the only method of treating temporary rhythm disturbances in this context. Temporary epicardial pacing has evolved from simple one-chamber systems to dual chamber, biatrial, and even biventricular systems. The first part of this two-part review provides an overview of the management of temporary epicardial pacing systems. Factors influencing the placement of the various types of epicardial wires and the routine care of a pacemaker-dependent patient are outlined, followed by a description of the diagnostic use of pacing wires, how to remove wires, and when to consider transition to permanent pacing. Special circumstances such as compatibility with magnetic resonance imaging and intra-aortic balloon pumps are also discussed. The second part of this review will describe the various pacing modes, and solutions to common pacing problems using various adjustable parameters.


Subject(s)
Cardiac Pacing, Artificial/methods , Cardiac Surgical Procedures , Postoperative Care/methods , Postoperative Complications/therapy , Arrhythmias, Cardiac/diagnosis , Arrhythmias, Cardiac/therapy , Humans , Pacemaker, Artificial , Postoperative Complications/diagnosis
20.
Br J Anaesth ; 94(4): 468-73, 2005 Apr.
Article in English | MEDLINE | ID: mdl-15695546

ABSTRACT

BACKGROUND: The vasodilatation characteristic of human septic shock is conventionally attributed to increased nitric oxide production, primarily by extrapolation of animal and human in vitro studies. There are no conclusive studies of human disease, and the cellular source of nitric oxide in human sepsis is not known. Haem oxygenase is upregulated by oxidative stress, but little is known about haem oxygenase expression in human sepsis. Haem oxygenase may modulate nitric oxide production, and may also have a direct effect on vascular tone. METHODS: Mesenteric arterial smooth muscle (ASM) (obtained during laparotomy) and peripheral blood mononuclear cells (PBMCs) were obtained from patients with early septic shock and from control patients. mRNA levels were determined by real-time RT-PCR. RESULTS: mRNA for inducible and endothelial nitric oxide synthase was reduced in both ASM and PBMCs from septic patients. In contrast, inducible haem oxygenase mRNA was increased in sepsis in both cell types. CONCLUSIONS: These results suggest that, rather than being induced, the enzymes which produce nitric oxide are reduced at this time point in human septic shock. Thus many of the in vitro models of sepsis studied to date may not fully replicate human disease. The increase in haem oxygenase expression confirms that these cells have been subjected to oxidative stress in sepsis. The activity of induced haem oxygenase may limit nitric oxide production, while possibly causing vasodilation through production of carbon monoxide.


Subject(s)
Heme Oxygenase (Decyclizing)/biosynthesis , Nitric Oxide Synthase/biosynthesis , Shock, Septic/enzymology , Adult , Aged , Aged, 80 and over , Down-Regulation , Heme Oxygenase (Decyclizing)/genetics , Humans , Leukocytes, Mononuclear/enzymology , Middle Aged , Muscle, Smooth, Vascular/enzymology , Nitric Oxide/biosynthesis , Nitric Oxide Synthase/genetics , Nitric Oxide Synthase Type II , Nitric Oxide Synthase Type III , RNA, Messenger/genetics , Reverse Transcriptase Polymerase Chain Reaction/methods , Up-Regulation
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