Delivery of anoxic gas mixtures in anaesthesia: case report and review of the struggle towards safer standards of care.

In 1983 a patient at The Alfred Hospital, Melbourne died during general anaesthesia for emergency surgery, in the weeks following maintenance to the operating theatre gas supply. In the ensuing investigation, it was revealed that he had been given 100% nitrous oxide throughout the anaesthetic due to the inadvertent crossing of the nitrous oxide and oxygen pipelines during the repair work. In this article we review the published literature on the delivery of hypoxic and anoxic gas mixtures, and the associated morbidity and mortality. We explore the developments that took place in the delivery of anaesthetic gases, and the unforeseen dangers associated with these advances. We consider the risks to patient safety when technological advances outpaced the implementation of essential safety standards. We investigate the events that pushed the development of safer standards of anaesthetic practice and patient monitoring, which have contributed to modern day theatre practice. Finally, we consider the risks that still exist in the hospital environment, and the need for on-going vigilance.

The introduction of expired air resuscitation into Surf Life Saving Australia.

Surf Life Saving Australia, which began in the early 1900s, initially adopted the indirect resuscitation methods used by the Royal Life Saving Society. As new indirect methods became available, both organisations adapted their resuscitation techniques and followed international developments closely. In the 1950s, accumulating evidence suggested that direct methods of resuscitation, such as mouth-to-mouth ventilation, might be more efficacious. Subsequently a number of investigations were carried out in Sydney at the Royal Prince Alfred Hospital on anaesthetised and paralysed patients. These experiments were recorded for an ABC documentary and reported at the International Convention on Life Saving Techniques held in Sydney in March 1960. Following the convention, Queensland Surf Life Saving conducted training sessions in cooperation with anaesthetists Roger Bennett and Tess Brophy (later Cramond), at St Andrew's Hospital in Brisbane. Two volunteers were anaesthetised and paralysed on two separate weekends to allow over one hundred people to gain experience in expired-air and bag-mask ventilation. One of the volunteers in these training exercises kindly provided much of the material that led to this paper, providing a first hand account of the experiments and an invaluable insight into the cooperation between anaesthetists and volunteer rescue associations.

On-line vs. in-house. Which billing system is right for your practice?

With medical billing becoming more difficult and confusing, you may decide that automated billing and collecting is just the answer you have been looking for to help take the mystery out of receivables. Currently, there are a myriad of in-house systems available to the physician while only a limited number of on-line systems exist. Which computer system is right for your practice? To answer this question, you will need to answer a series of other questions first. To help define your business problem, you must fully understand your practice. The following questions will allow you to analyze your office.

A cohort and database study of airway management in patients undergoing thyroidectomy for retrosternal goitre.

Patients undergoing thyroid surgery with retrosternal goitre may raise concerns for the anaesthetist, especially airway management. We reviewed a multicentre prospective thyroid surgery database and extracted data for those patients with retrosternal goitre. Additionally, we reviewed the anaesthetic charts of patients with retrosternal goitre at our institution to identify the anaesthetic induction technique and airway management. Of 4572 patients in the database, 919 (20%) had a retrosternal goitre. Two cases of early postoperative tracheomalacia were reported, one in the retrosternal group. Despite some very large goitres, no patient required tracheostomy or cardiopulmonary bypass and there were no perioperative deaths. In the subset of 133 patients managed at our institution over six years, there were no major adverse anaesthetic outcomes and no patient had a failed airway or tracheomalacia. In the latter cohort, of 32 (24%) patients identified as having a potentially difficult airway, 17 underwent awake fibreoptic tracheal intubation, but two of these were abandoned and converted to intravenous induction and general anaesthesia. Eleven had inhalational induction; two of these were also abandoned and converted to intravenous induction and general anaesthesia. Of those suspected as having a difficult airway, 28 (87.5%) subsequently had direct laryngoscopy where the laryngeal inlet was clearly visible. We found no good evidence that thyroid surgery patients with retrosternal goitre, with or without symptoms and signs of tracheal compression, present the experienced anaesthetist with an airway that cannot be managed using conventional techniques. This does not preclude the need for multidisciplinary discussion and planning.