Patients who exhibit high systemic inflammation after cardiac surgery may benefit most from pre-emptive anti-inflammatory treatments. In this secondary analysis (n = 813) of the randomised, double-blind Intraoperative High-Dose Dexamethasone for Cardiac Surgery trial, we set out to develop an inflammation risk prediction model and assess whether patients at higher risk benefit from a single intraoperative dose of dexamethasone (1 mg/kg). Inflammation risk before surgery was quantified from a linear regression model developed in the placebo arm, relating preoperatively available covariates to peak postoperative C-reactive protein. The primary endpoint was the interaction between inflammation risk and the peak postoperative C-reactive protein reduction associated with dexamethasone treatment. The impact of dexamethasone on the main clinical outcome (a composite of death, myocardial infarction, stroke, renal failure, or respiratory failure within 30 days) was also explored in relation to inflammation risk. Preoperatively available covariates explained a minority of peak postoperative C-reactive protein variation and were not suitable for clinical application (R2 = 0.058, P = 0.012); C-reactive protein before surgery (excluded above 10 mg/L) was the most predictive covariate (P < 0.001). The anti-inflammatory effect of dexamethasone increased as the inflammation risk increased (-0.689 mg/L per unit predicted peak C-reactive protein, P = 0.002 for interaction). No treatment-effect heterogeneity was detected for the main clinical outcome (P = 0.167 for interaction). Overall, risk predictions from a model of inflammation after cardiac surgery were associated with the degree of peak postoperative C-reactive protein reduction derived from dexamethasone treatment. Future work should explore the impact of this phenomenon on clinical outcomes in larger surgical populations.

A 19-year-old woman with known maple syrup urine disease presented to hospital with metabolic crisis in the setting of influenza type A infection and intractable vomiting, rapidly progressing to acute cerebral oedema manifesting as refractory seizures and decreased level of consciousness needing emergency intubation and mechanical ventilation, continuous veno-venous haemodiafiltration and thiopentone coma. A computed tomography scan and magnetic resonance imaging of the brain demonstrated classic signs of cerebral oedema secondary to a metabolic crisis from the metabolic disorder. Her management posed multiple challenges to all teams involved due to lack of familiarity and experience in managing this clinical scenario in the adult intensive care setting.

The practice of anaesthetists relating to the administration of intraoperative oxygen has not been previously quantified in Australia and New Zealand. The optimal regimen of intraoperative oxygen administration to patients undergoing surgery under general anaesthesia is not known, and international recommendations for oxygen therapy are contradictory; the World Health Organization (WHO) recommend administering an intraoperative fraction of inspired oxygen of at least 0.8, while the World Federation of Societies of Anaesthesiologists, British Thoracic Society, and Thoracic Society of Australia and New Zealand recommend a more restrictive approach. We conducted a prospective observational study to describe the pattern of intraoperative oxygen administration among anaesthetists in Australia and New Zealand and, second, to determine the proportion of anaesthetists who administer intraoperative inspired oxygen in accordance with the WHO recommendations. We identified 150 anaesthetists from ten metropolitan hospitals in Australia and New Zealand and observed the patterns of intraoperative oxygen administration to American Society of Anesthesiologists physical status classification (ASA) 3 or 4 patients undergoing prolonged surgery under general anaesthesia. The median (interquartile range) intraoperative time-weighted mean fraction of inspired oxygen (FiO2) for all participants in the study was 0.47 (0.40-0.55). Three out of 150 anaesthetists (2%, 95% confidence interval 0.4 to 5.7) administered an average intraoperative FiO2 of at least 0.8. These findings indicate that most anaesthetists routinely administer an intermediate level of oxygen for ASA 3 or 4 adult patients undergoing prolonged surgery in Australia and New Zealand, rather than down-titrating inspired oxygen to a target pulse oximetry reading (SpO2) or administering liberal perioperative oxygen therapy in line with the current WHO recommendation.

Ocular hypotony can occur from many causes, including eye trauma, ophthalmic surgery and ophthalmic regional anaesthesia-related complications. Some of these patients require surgical intervention(s) necessitating repeat anaesthesia. While surgical management of these patients is well described in the literature, the anaesthetic management is seldom discussed. The hypotonous eye may also have altered globe anatomy, meaning that the usual ocular proprioceptive feedbacks during regional ophthalmic block may be altered or lost, leading to higher risk of inadvertent globe injury. In an 'open globe' there is a risk of sight-threatening expulsive choroidal haemorrhage as a consequence of ophthalmic block or general anaesthesia. This narrative review describes the physiology of aqueous humour, the risk factors associated with ophthalmic regional anaesthesia-related ocular hypotony, the surgical management, and a special emphasis on anaesthetic management. Traumatic hypotony usually requires urgent surgical repair, whereas iatrogenic hypotony may be less urgent, with many cases scheduled as elective procedures. There is no universal best anaesthetic technique. Topical anaesthesia and regional ophthalmic block, with some technique modifications, are suitable in many mild-to-moderate cases, whilst general anaesthesia may be required for complex and longer procedures, and severely distorted globes.

Papua New Guinea is a Pacific country that remains an enigma to the world at large. Despite massive geographical challenges due to mountainous terrain, remote islands, poverty, and with 80% of the population of over eight million living in rural villages, Papua New Guinea has managed to develop national medical and postgraduate specialty training. The first recorded anaesthetic was administered in Papua New Guinea in 1880 and the first anaesthetist trained in 1968. The University of Papua New Guinea graduated its first diploma in anaesthesia candidate in 1986 and its first master of medicine candidate in anaesthesiology in 1991. As of December 2021, there have been 82 diplomas and 40 masters of medicine awarded. We review the factors and influences bearing on the development of physician anaesthesia training in Papua New Guinea over this period. Many of the people involved have contributed information used in this article.

Laryngotracheal injury is an increasingly common complication of intubation and mechanical ventilation, with an estimated 87% of intubated and ventilated patients developing a laryngotracheal injury often preventing their rehabilitation from acute illness. Laryngotracheal injuries encompass a diverse set of pathologies including inflammation and oedema in addition to vocal cord ulceration and paralysis, granuloma, stenosis, and scarring. The existing literature has identified several factors including intubation duration, endotracheal tube size, type and cuff pressures, and technical factors including the skill and experience of the endoscopist. Despite these associations, a key aspect in the sequelae of laryngotracheal injuries is due to reflux and is not clearly related to iatrogenic and mechanical factors.Laryngopharyngeal reflux is a type of reflux that contaminates the upper aerodigestive tract. The combination of patient positioning and continuous nasogastric tube feeding act to affect the upper aerodigestive tract with acidic and non-acidic refluxate that causes direct and indirect mucosal injury impeding healing.Despite laryngopharyngeal reflux being an established and recognised causative factor of upper aerodigestive tract inflammatory pathology and laryngotracheal injury, it is very understudied in critical care. Further, there is yet to be an agreed pathway to assess, manage and prevent laryngotracheal injury in intubated and ventilated patients. The incidence of laryngopharyngeal reflux in the intubated and mechanically ventilated patient in the intensive care unit is currently unknown. Prospective studies may allow us to understand further potential mechanisms of upper aerodigestive tract injury due to laryngopharyngeal reflux and herald the development of preventative and management strategies of laryngopharyngeal reflux-mediated upper aerodigestive tract injury in critically ill patients.