Skin injuries are a major healthcare problem that are not well understood or prevented in the critically ill, suggesting that underappreciated variables are contributing. This pilot study tested the hypothesis that perfusion-related factors contribute to skin injuries diagnosed as hospital-acquired pressure injuries (HAPIs). A total of 533 adult patients were followed over 2574 critical care days (mean age 62.4, standard deviation (SD) 14.3 years, mean body mass index 30.4 (SD 7.4) kg/m, 36.4% female). This was a secondary analysis of prospective, non-randomised clinical data from an intensive care unit at a large urban teaching hospital. Factors related to perfusion, specifically two or more infusions of vasopressors/inotropes, temporary mechanical circulatory support (MCS), extracorporeal membrane oxygenation, and durable MCS, were analysed to determine whether they were more strongly associated with HAPIs than immobility due to prolonged mechanical ventilation (>72 h) or operating room time (>6 h). Patients diagnosed with a HAPI had a statistically significant higher risk of being exposed to variables related to perfusion and immobility ( < 0.05 for each variable). Perfusion-related variables, except durable MCS, had a larger effect on skin breakdown (number needed to harm (NNH) 4-10) than immobility-associated variables (NNH 12-17). The finding that perfusion-related variables predicted HAPIs may warrant consideration of alternative diagnoses, such as skin failure due to impaired perfusion as a pathophysiological process that occurs concurrently with multisystem organ failure. Differentiation of skin injuries primarily from circulatory malfunction, rather than external pressure, may guide the development of more effective treatment and prevention protocols. This pilot study suggests that the contribution of perfusion to skin injuries should be explored further.

The Complex Decision Pathway (CDP) is a novel perioperative shared decision-making pathway that was established in the Bay of Plenty, New Zealand in 2018. Unique features of the pathway include the use of a structured communication tool to facilitate a goals-of-care conversation in addition to medical assessment, and the use of a tikanga Māori framework for Māori patients. From May 2019 until May 2022, 81 patients attending the CDP clinic were recruited to a prospective study of their demographics, health status and experience at the time of presentation, along with outcomes and opinions over the subsequent 12 months. Participants were mostly elderly and frail with multiple comorbidities, and just over half of participants chose to undergo surgery. Participants who chose, or were recommended, not to undergo surgery were older, more comorbid and had worse outcomes over the subsequent 12 months. Qualitative data suggested an overall positive patient experience of the pathway, and an economic analysis demonstrated its cost-effectiveness. Overall, the data presented here suggested that the CDP assisted in risk-stratifying patients into operative and non-operative groups, provided a positive patient experience, and was a cost-effective intervention.

The COVID-19 pandemic disrupted medical conferences, where restrictions on public gatherings resulted in the postponement or cancellation of in-person meetings. Virtual events emerged as a substitute, providing a mechanism for scientific collaboration and continuing medical education with the additional benefit of low environmental impact. However, digital events may not meet all the needs of delegates, such as professional networking and social connection. In this report, we describe the methods used to minimise the carbon footprint of the 2023 Australian and New Zealand College of Anaesthetists' Annual Scientific Meeting, a conference with approximately 2000 in-person and 500 virtual delegates. A core group led the initiative, with all conference participants invited to contribute to this goal. A prospective prediction of carbon generation was undertaken, followed by the implementation of strategies to minimise and then measure the total carbon footprint of the event. Post-event calculations assessed the conference as better than carbon-neutral; however, delegate travel was not included in the analysis and therefore this result is tempered. Off-site workshops including virtual offerings were also not included in the analysis. We encourage medical conference organisers to collaborate with all stakeholders to embed low carbon-generation choices for their meetings where education, networking and social needs are also met.

Renal chloride metabolism is currently poorly understood but may serve as both a diagnostic and a treatment approach for acute kidney injury. We investigated whether plasma chloride, ammonia and glutamine as well as urinary chloride, ammonium and glutamine concentrations may serve as markers for acute kidney injury in paediatric patients. We conducted a prospective observational trial in a tertiary care paediatric intensive care unit. Ninety-one patients after cardiopulmonary bypass surgery were enrolled. Plasma glutamine, creatinine, (serum) albumin, urinary electrolytes and glutamine were collected pre-cardiopulmonary bypass surgery, at paediatric intensive care unit admission, and at 6, 12, 24, 48 and 72 h after paediatric intensive care unit admission. The urinary strong ion difference was calculated. The median urinary chloride excretion decreased from 51 mmol/L pre-cardiopulmonary bypass to 25 mmol/L at paediatric intensive care unit admission, and increased from 24 h onwards. Patients with acute kidney injury had lower urinary chloride excretion than those without. The median urinary strong ion difference was 59 mmol/L pre-cardiopulmonary bypass, rose to 131 mmol/L at 24 h and fell to 20 mmol/L at 72 h. The plasma chloride rose from 105 mmol/L pre-cardiopulmonary bypass to a maximum of 109 mmol/L at 24 h. At 24 h the plasma chloride concentration was associated with the presence of acute kidney injury. There was no association between plasma or urinary amino acids and chloride excretion or kidney injury. In conclusion, renal chloride excretion decreased in all patients, although this decrease was more pronounced in patients with acute kidney injury. Our findings may reflect a response of the kidneys to critical illness, and acute kidney injury may make these changes more pronounced. Targeting chloride metabolism may offer treatment approaches to acute kidney injury.

This study aimed to assess the availability, design, and contents of difficult airway trolleys in hospitals in Victoria, Australia. A survey audit was conducted with a 92.3% reply rate, and the responses from 22 major Victorian hospitals were analysed. The results showed that difficult airway trolleys were available in 100% of operating theatres, emergency departments and intensive care units, and the rate of standardisation was high. Compliance with recommended design features and resources was on average 68.3%. There was no significant difference in the compliance rate of major tertiary centres compared with other hospitals. The carriage of non-essential items was reduced compared with earlier audits. However, there was heterogeneity in the brands of supraglottic airway devices, videolaryngoscopes and cognitive aids used. The study highlights the need for ongoing improvement to the organization and content of difficult airway trolleys, and for further discussion regarding the safety of equipment variation across institutions.

Sub-Tenon's block has a superior safety profile and life-threatening complications such as cardiovascular collapse and brainstem anaesthesia are extremely rare. We report a case of cardiorespiratory collapse following bilateral sub-Tenon's blocks at the conclusion of a laser photocoagulation procedure under general anaesthesia. The cause was most likely brainstem anaesthesia. We explore and discuss the likely mechanisms and other potential differential diagnoses. It highlights the importance of maintaining vigilance following an eye block. Attention should not falter upon completing a block or at the conclusion of a case, regardless of its type or safety profile. This case also illustrates how the presence of general anaesthesia may obscure and delay the diagnosis of brainstem anaesthesia.

Occupationally acquired COVID-19 is a hazard for healthcare workers (HCWs). In four hospitals of the Metro North Hospitals and Health Service in Queensland, Australia, we invited HCWs to report the nature of any anaesthesia interactions with COVID-19-positive and COVID-19-suspect patients. This was to assist workforce planning in future pandemics. Data collection consisted of three phases; 1) participating HCWs recorded details of episodes of care (EOCs) with COVID-19-positive or COVID-19-suspect patients; 2) these HCWs were invited to complete a follow-up survey about their own health status regarding COVID-19 infections; 3) electronic health records were used to assess patient demographics, infectious status and outcomes. Between 21 March 2020 and 17 May 2022, 63 anaesthesia HCWs reported 90 EOCs with 67 unique patients. The median (interquartile range (IQR)) age of the HCWs was 40.5 years (34-46); 55% (34/62) were male, 62% (39/63) were consultants and 21% (13/63) were registrars. The median (IQR) age of patients was 39 (28-63) years. Personal protective equipment (PPE) was deemed to be appropriate by the HCWs in (86/88) 98% of the EOCs. Twenty-four HCWs (38%) responded to a follow-up survey. Of 12 HCWs who subsequently tested positive to COVID-19, only four had cared for a COVID-19-positive patient in the two weeks prior to their diagnosis. Most responding HCWs perceived they contracted COVID-19 in the community, experiencing mild illness. We found relatively low COVID-19 case numbers, high PPE use and low transmission of COVID-19 within the hospital setting.

Laparoscopic robot-assisted colorectal surgery can pose significant haemodynamic challenges for patients with severe aortic regurgitation. The increased afterload caused by pneumoperitoneum and aortic compression, along with concurrent factors like hypercarbia, Trendelenburg positioning and ventilatory impairment, can worsen aortic regurgitation, leading to myocardial ischaemia and heart failure. Transoesophageal echocardiography (TOE) assists haemodynamic management intraoperatively but requires subspecialist skills and enables limited inferences to be drawn regarding the impact of afterload on myocardial performance. Minimally invasive haemodynamic monitoring enabling real-time visualisation of a patient's 'pressure field' has been suggested as a potential adjunct or alternative to TOE, with the added advantage of providing continuous quantitative information about both stroke volume and the afterload to ventricular ejection in a single visualisation. We describe an example of successful concurrent use of pressure field haemodynamic monitoring and TOE in a patient with severe aortic regurgitation having a prolonged laparoscopic robot-assisted pelvic exenteration.

Emergence delirium, characterised by inconsolable crying, perceptual disturbances and thrashing, occurs in young children during the recovery phase from general anaesthesia. Our aim was to determine whether timing of laryngeal mask airway removal (deeply anaesthetised versus awake) influenced the incidence of emergence delirium in children after tonsillectomy. A single-centre, randomised controlled trial was conducted at Albury Wodonga Health, a regional hospital in Australia. Included patients were two to seven years old, American Society of Anesthesiologists physical status classification 1-2, undergoing elective tonsillectomy (with or without adenoidectomy or grommet insertion) under general anaesthesia. Patients were randomised to have their laryngeal mask removed whilst deeply anaesthetised (in the operating theatre) or after awakening (in the post-anaesthesia care unit (PACU)). Pediatric Anesthesia Emergence Delirium score was determined at 5 and 20 min after eye opening, and frequency of complications (cough, vomiting, excessive salivation, oxygen desaturation and laryngospasm) in the PACU were recorded. Sixty-two patients were randomised to deep laryngeal mask removal and 62 to awake. In the awake versus deep groups, 33 (53%) versus 40 (65%) participants had emergence delirium at 5 min (odds ratio (OR) 0.63, 95% confidence interval (CI) 0.30 to 1.29,  = 0.20). At 20 min, 18 (29%) . 19 (31%) participants had emergence delirium (OR 0.93, 95% CI 0.43 to 2.00,  = 0.88). A greater incidence of most PACU complications was observed in the awake versus deep group; cough (24% . 8%), vomiting (8% . 0%), excessive salivation (23% . 8%) and oxygen desaturation (16% . 0%). We found no significant difference between the two techniques in terms of preventing emergence delirium. However, other PACU complications were more frequent with awake removal.

Preoperative assessment of functional capacity with the six-minute walk test (6MWT) allows for estimation of surgical risk and targeted triage to prehabilitation services. Patient with abdominal and pelvic cancers have worse preoperative function compared with the general population. However, six-minute walk distance (6MWD) reference values from cancer patients are unknown, which limits the interpretation of 6MWT in this population. This study aimed to establish an explanatory reference value model for preoperative 6MWD in patients with abdominal or pelvic cancers undergoing elective surgery. Adult patients undergoing surgery for abdominal or pelvic cancers at major international hospitals were included. The 6MWT was assessed before surgery using a standardised protocol. Anthropometric data including age, sex, height, weight and body mass index (BMI) were collected and included in multiple linear regression analysis to model preoperative 6MWD. A total of 742 patients were included. Age, height and BMI were correlated with 6MWD. Six regression models were estimated, including two from the entire cohort, two from the subset of males and two from the subset of females. A sex-neutral model was the most representative, explaining 15% of the variance in 6MWD (6MWD = 761.00-3.00 * Age (years) -2.86 * BMI (kg/m) - 48.09 * Sex (M1, F2)). The explored regression models, using anthropometric variables, poorly explained the variance between measured and modelled 6MWD, which suggests that these models have no clinical utility in the cancer population. Consideration of additional, non-anthropometric variables may improve regression modelling of preoperative 6MWD in patients in abdominal and pelvic cancers.

We present a case of severe taipan envenoming in northern New South Wales in a 68-year-old man. He developed severe neurotoxicity requiring intubation and ventilation, venom-induced consumption coagulopathy, myotoxicity and thrombotic microangiopathy with acute kidney injury requiring dialysis. He was administered brown and tiger snake antivenom consistent with guidelines and snake occurrence in the region. Taipan venom was detected in serum (72 ng/ml) following concern about the severity of neurotoxicity, clinical toxicology consultation and a concurrent report of a taipan in the area. Based on this it would be prudent to stock and consider treating with polyvalent antivenom in north-eastern New South Wales and south-eastern Queensland.