SummaryThe clinical features of propofol infusion syndrome (PRIS) are acute refractory bradycardia leading to asystole, in the presence of one or more of the following: metabolic acidosis (base deficit > 10 mmol.l−1), rhabdomyolysis, hyperlipidaemia, and enlarged or fatty liver. There is an association between PRIS and propofol infusions at doses higher than 4 mg.kg−1.h−1 for greater than 48 h duration. Sixty‐one patients with PRIS have been recorded in the literature, with deaths in 20 paediatric and 18 adult patients. Seven of these patients (four paediatric and three adult patients) developed PRIS during anaesthesia. It is proposed that the syndrome may be caused by either a direct mitochondrial respiratory chain inhibition or impaired mitochondrial fatty acid metabolism mediated by propofol. An early sign of cardiac instability associated with the syndrome is the development of right bundle branch block with convex‐curved (‘coved type’) ST elevation in the right praecordial leads (V1 to V3) of the electrocardiogram. Predisposing factors include young age, severe critical illness of central nervous system or respiratory origin, exogenous catecholamine or glucocorticoid administration, inadequate carbohydrate intake and subclinical mitochondrial disease. Treatment options are limited. Haemodialysis or haemoperfusion with cardiorespiratory support has been the most successful treatment.

This review examines the science and methodology of blood conservation in modern anaesthetic and surgical practice. Blood transfusion is associated with increased morbidity and mortality in all surgical patients, and the reduction or even elimination of transfusion has been and continues to be the subject of much research. Blood substitutes, despite extensive investigation, have not been proved successful in trials to date, and none have entered clinical practice. Pharmacological treatments include antifibrinolytic drugs (although aprotinin is no longer in clinical use), recombinant factor VIIa, desmopressin, erythropoietin and topical haemostatic agents, and the role of each of these is discussed. Autologous blood transfusion has recently fallen in popularity; however, cell salvage is almost ubiquitous in its use throughout Europe. Anaesthetic and surgical techniques may also be refined to improve blood conservation. Blood transfusion guidelines and protocols are strongly recommended, and repetitive audit and education are instrumental in reducing blood transfusion.

Dysphagia is common after stroke and is associated with increased morbidity and mortality. Predicting those who are likely to have significant prolonged dysphagia is not possible at present. This study was undertaken to validate the Royal Adelaide Prognostic Index for Dysphagic Stroke (RAPIDS) in the prediction of prolonged dysphagia following acute stroke using clinical and radiographic features. A prospective study of unselected, consecutive admissions to the Royal Adelaide Hospital acute stroke unit was undertaken. Clinical and radiographic features applicable to the RAPIDS test were calculated and the sensitivity, specificity, and likelihood ratio for predicting prolonged dysphagia were calculated with 95% confidence intervals (CI). Of 104 subjects admitted with acute stroke, 55 (53%) had dysphagia and 20 (19%) had dysphagia requiring nonoral feeding/hydration for 14 days or more or died while dysphagic prior to 14 days. The RAPIDS test had sensitivity of 90% (95% CI = 70-97%) and specificity of 92% (95% CI - 84-96%) for predicting this latter group of patients. We conclude that the RAPIDS test can be used early to identify patients likely to have prolonged dysphagia. This test could form a basis for selection of patients for trials of nonoral feeding methods.

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This retrospective study aimed to determine the prevalence of preoperative anaemia, hypochromia and microcytosis in cardiac surgery patients. Data was analysed for 943 patients (over a two-year period) undergoing coronary artery bypass graft, valve or combined coronary artery bypass graft and valve surgery at a tertiary hospital in South Australia. Overall prevalence of preoperative anaemia was 25.2%, greater in males than females (27.6 vs 19.9%, P <0.01). Of patients with preoperative anaemia, 19.3% had reduced red cell indices (mean corpuscular haemoglobin and/or mean corpuscular volume) compared to 4% of patients without anaemia. The proportion of anaemic patients with low red cell indices was significantly higher in women <50 years and 50-65 years, compared to those >65 years of age (P=0.003). Anaemic patients with low red cell indices had lower preoperative haemoglobin than anaemic patients without low red cell indices (median haemoglobin 112 vs 120 g/l, P=0.008). Compared to non-anaemic patients, anaemic patients had higher transfusion rates (79.8 vs 46.4%, P <0.0001), which were greater in those with reduced red cell indices compared to those with normal red cell indices (93.5 vs 76.6%, P=0.01). This study demonstrated a high prevalence of preoperative anaemia, microcytosis and hypochromia in cardiac surgical patients.