Rescue sedation administered to mechanically ventilated patients undergoing interhospital transfer by a South African aeromedical service: A retrospective review.

Elastomeric Pumps for Continuous Subcutaneous Infusion of Symptom Control Medication on Discharge.

ABSTRACTBackgroundThe reported incidence of blood product transfusion reaction (TR) in cats varies greatly.ObjectiveEvaluate the incidence and practices surrounding acute TRs in cats receiving feline blood products, using Transfusion Reaction Small Animal Consensus Statement (TRACS) definitions.AnimalsCats (n = 444) that received feline blood products (n = 608) between March 2022 and January 2024.MethodsProspective, multicenter observational study at referral hospitals (n = 14) in the United States, United Kingdom, and Australia documenting the incidence of acute TRs in cats receiving allogenic blood transfusions.ResultsAcute TR incidence was 7.8% (95% confidence interval [CI], 5.6–10.6) for red blood cell (RBC)‐containing products and 1.1% (95% CI, 0.0–5.9) for plasma products. Febrile nonhemolytic transfusion reactions (FNHTRs) were the most common in RBC‐containing products (incidence, 5.7%; 95% CI, 3.8–8.1). Age of RBC unit (adjusted odds ratio [aOR], 1.04 per day; 95% CI, 1.00–1.07) and administering a RBC unit with an infusion pump rather than a syringe driver (aOR, 4.7; 95% CI, 1.43–15.54) were associated with an increased odds of FNHTR. Of transfusions discontinued (n = 28) because of a potential TR, 46.4% did not fulfill TRACS criteria for any TR. Death occurred within 24 h of a transfusion event in 18.3% but was not associated with the development of a TR (odds ratio [OR], 0.76; 95% CI, 0.29–1.99).Conclusions and Clinical ImportanceTransfusion reaction incidence in cats, as defined using TRACS guidelines, is reported. Febrile nonhemolytic TRs were the most common and were associated with increasing RBC unit age and administering RBC via an infusion pump.

To determine the distribution of injectate (iohexol) at the feline sacrococcygeal space using CT and thereby identify the volume necessary to reach the 10th thoracic intervertebral foramina (T10-T11), where nociceptive neurons from the ovaries enter the spinal cord. 7 healthy, purpose-bred, 1- to 2-year-old intact female domestic shorthair cats were anesthetized and positioned in sternal recumbency. After baseline vertebral column CT, a stimulating needle connected to a nerve stimulator (current, 0.2 mA; frequency, 2 Hz; pulse width, 0.1 milliseconds) was inserted at the sacrococcygeal space. After distal tail twitching was observed, a syringe driver injected iohexol (44 mg/mL; 0.25 mL/kg over 30 seconds). Computed tomography was performed 30 seconds after the injection ended. This was repeated 3 times, with 4 minutes separating the start of each injection. A linear mixed-effects model was constructed to determine if the number of vertebrae traversed as the iohexol distributed cranially could be predicted as a function of injectate volume, side of vertebral column, and their interaction (cat as a random effect). The association between injectate volume and number of vertebrae traversed was significant. The volume required to reach the T10-T11 intervertebral foramen bilaterally was 0.75 mL/kg in 3 cats and 1.0 mL/kg in 3 cats; in 1 cat, 1.0 mL/kg did not reach this level. Sacrococcygeal epidural injection of 0.75 to 1.0 mL/kg or more of local anesthetic may be required for segmental analgesia for feline ovariohysterectomy. The volume required is greater than the volume injected epidurally in previous studies and could increase the risk of producing hemodynamic side effects.

ABSTRACTPurposeNucleus augmentation has been proposed as an early‐stage intervention for intervertebral disc degeneration and involves the injection of a biomaterial into the nucleus to restore disc height and functionality. The aim of this work was to identify clinically relevant quantitative measures that indicate the mechanical performance of the disc following nucleus augmentation.MethodBovine tail bone‐disc‐bone units (n = 22) were mechanically tested under cyclic loading sequentially in native, artificially degenerated, and treated states. Treatment involved injection of a peptide‐glycosaminoglycan mixture into the degenerated disc to a predetermined load using a syringe driver with an integrated force sensor. The stiffness restoration of the treatment was determined by comparing the biomechanical behavior of the native state to the treated state of each disc. The stiffness restoration was then compared against clinically quantifiable parameters.ResultsNo significant biomechanical differences were observed between the native and treated states, but both were significantly different from the degenerated state. The force delivered during injection was found to ramp to a steady state, followed by a final rapid increase; however, all measures associated with injection force poorly correlated with the level of stiffness restoration. Volume injected and change in disc height from injection had the strongest relationship to stiffness restoration.ConclusionThis work showed that measuring the injection force for injectable treatments of the disc can provide lower and upper limits for delivery, but direct measures are stronger indicators of disc stiffness restoration.

With the increasing use of aeromedical transport for critically ill patients, it is essential to understand the impact of pressure changes on drug infusion delivery systems. As airplanes ascend and descend, gases/bubbles are released from solutions when ambient pressure decreases and dissolves when pressure increases. This may affect mechanical fluid delivery systems and cause clinically significant changes, especially within a critical care setting. We aimed to evaluate the impact of pressure changes on volumetric pumps and syringe drivers. An in vitro study of six volumetric pumps and eight syringe drivers was conducted in a hypobaric chamber to mimic pressure changes during flights. Infusion devices were set to deliver water at 0.2 ml ⋅ h-1 and infused volumes were measured. There were 15 open-ended syringes also studied. During ascent, syringe drivers and volumetric pumps over-delivered 173 µL and 38 µL of fluid. During descent, syringe drivers under-delivered by 166 µL, whereas volumetric pumps under-delivered by 9 µL. Syringe drivers experienced statistically significant changes in fluid delivery during both ascent and descent. In volumetric pumps, only the descent phase infusion differed significantly from other phases. The volume of fluid expansion is dependent on volume and the mechanical properties of the fluid. Decreasing ambient pressure causes bubble formation, which displaces fluid, and increasing ambient pressure causes bubble reabsorption in mechanical infusion devices. Hence, atmospheric pressure changes during air travel may alter fluid delivery from medical fluid delivery systems and affect critically ill patients who require both aeromedical evacuation and accurate infusion of drugs. Fan KS, Paterson M, Shojaee-Moradie F, Manoli A, Edwards V, Lee V, Hutchison E, Gifford RM, Parsons IT, Koehler G, Mathieu C, Mader JK, King BR, Russell-Jones D; EASA Consortium. Performance of fluid infusion systems in the changing atmospheric pressures encountered in aviation. Aerosp Med Hum Perform. 2025; 96(1):4-11.

With the increasing use of aeromedical transport for critically ill patients, it is essential to understand the impact of pressure changes on drug infusion delivery systems. As airplanes ascend and descend, gases/bubbles are released from solutions when ambient pressure decreases and dissolves when pressure increases. This may affect mechanical fluid delivery systems and cause clinically significant changes, especially within a critical care setting. We aimed to evaluate the impact of pressure changes on volumetric pumps and syringe drivers. An in vitro study of six volumetric pumps and eight syringe drivers was conducted in a hypobaric chamber to mimic pressure changes during flights. Infusion devices were set to deliver water at 0.2 ml ⋅ h-1 and infused volumes were measured. There were 15 open-ended syringes also studied. During ascent, syringe drivers and volumetric pumps over-delivered 173 µL and 38 µL of fluid. During descent, syringe drivers under-delivered by 166 µL, whereas volumetric pumps under-delivered by 9 µL. Syringe drivers experienced statistically significant changes in fluid delivery during both ascent and descent. In volumetric pumps, only the descent phase infusion differed significantly from other phases. The volume of fluid expansion is dependent on volume and the mechanical properties of the fluid. Decreasing ambient pressure causes bubble formation, which displaces fluid, and increasing ambient pressure causes bubble reabsorption in mechanical infusion devices. Hence, atmospheric pressure changes during air travel may alter fluid delivery from medical fluid delivery systems and affect critically ill patients who require both aeromedical evacuation and accurate infusion of drugs. Fan KS, Paterson M, Shojaee-Moradie F, Manoli A, Edwards V, Lee V, Hutchison E, Gifford RM, Parsons IT, Koehler G, Mathieu C, Mader JK, King BR, Russell-Jones D; EASA Consortium. Performance of fluid infusion systems in the changing atmospheric pressures encountered in aviation. Aerosp Med Hum Perform. 2025; 96(1):4-11.

Chyme reinfusion therapy (CRT) is a safe and effective method to improve nutritional outcomes and promote intestinal adaptation in patients with stomas. This practice involves refeeding the proximal stoma output, down the distal limb, and mimics a state of intestinal continuity; thereby promoting growth and adaption of the distal bowel. Despite its promise, CRT in neonates is a relatively underutilised practice and can be of significant value in neonates with congenital bowel anomalies or necrotising enterocolitis. We aimed to identify the frequency, methodology and adverse effects associated with CRT in our neonatal population. We aimed to identify the frequency, methodology and adverse events associated with CRT in our neonatal population. A ten-year retrospective cohort study was conducted using database searches at two major paediatric hospitals in New Zealand. All patients with suitable anatomy were identified, and data on CRT methodology and outcomes were recorded. Of the 49 eligible neonates, 23 (47%) underwent CRT. Indications for CRT included high stoma output, malnutrition with poor weight gain, and routine refeeding prior to stoma reversal. A nasogastric feeding tube was inserted into the distal limb and collected chyme was reinfused via manual bolus or automated syringe driver. The median (IQR) weight gain increased from 13.9 (3.50-22.89) to 24.37 (19.68-29.99) g/day during CRT (p = 0.04). 18 infections requiring medical intervention but unrelated to CRT occurred in 13 patients (56%). Amongst our cohort, there was a high rate of non-infectious events, including peri-stomal skin irritation (60%), stoma prolapse (43%) and stomal bleeding (26%). CRT is an underutilised method of improving nutrition in neonates with intestinal failure. Premature neonates requiring double enterostomy formation are at high risk of infectious and non-infectious complications, but few of these are related to CRT. Standardised protocols providing clear eligibility criteria and detailed methodology for CRT are required to promote uniform utilisation of this practice.

<p>The primary aim of this quality improvement initiative is to evaluate and enhance prescription practices for syringe drivers among junior doctors in the oncology department.</p>

Soft pneumatic actuators (SPAs) are commonly used in various applications because of their structural compliance, low cost, ease of manufacture, high adaptability, and safe human-robot interaction. The traditional approach for achieving proportional control of soft pneumatic robots requires the use of industrial proportional valves or syringe drivers, which are not only rigid and bulky but also hard to be integrated into the body of soft robots. In our previous research, we developed a Magnetorheological elastomer (MRE)-based soft valve that showed advantages for controlling SPAs due to its compliance, compactness, robustness, and compatibility for continuous pressure modulation. Modern soft robots with multiple chambers require more MRE valves onboard for their control. However, merely packing more MRE valves for soft robots can cause problems like magnetic interference, flow rate deviation, and overheating. Therefore, in this study, we proposed a two-dimensional MRE valve array design to solve issues of magnetic interference and overheating when expanding from a single MRE proportional valve into an integrated array. The magnetic interference and the overheating problem were investigated through multiphysics simulation, bringing the optimal choice of valve spacing (1.2 times the single valve diameter), magnetic coil pole arrangement (same pole), and the cooling system design (internal cooling chamber with flowing water). Physical experiments showed that our MRE valve array maintained its original flowrate performance with low magnetic interference (0.89 mT) and low coil temperature (under 73.9°C for 5 min).

Role of Coriolis flow measurement technology in validation of model of syringe driver performance

Bio-impedance analysis (BIA) has been widely investigated for hemodynamic monitoring. However, previous works rarely modelled two synchronously pulsatile arteries (representing the radial and ulnar arteries) in the wrist/forearm model. This work aims to clarify and quantify the influences of two pulsatile arteries on BIA. First, two blood-filled arteries were structured in a 3D wrist segment using the finite element method (FEM). Afterwards, an easy-to-produce two-arteries artificial wrist was fabricated with two components: gelatine-based surrounding tissue phantom and saline blood phantom. A syringe driver was utilised to constrict the arteries, and the impedance signals were measured using a Multi-frequency Impedance Analyser (MFIA). Both simulation and experimental results demonstrated the non-negligible influences of the ulnar artery on the overall BIA, inducing unwanted resistance changes to the acquired signals from the radial artery. The phantom experiments revealed the summation of the individual resistance changes caused by a single pulsatile artery was approximately equal to the measured resistance change caused by two synchronously pulsatile arteries, confirming the measured impedance signal at the wrist contains the pulsatile information from both arteries. This work is the first simulation and phantom investigation into two synchronously pulsatile arteries under BIA in the distal forearm, providing a better insight and understanding in the morphology of measured impedance signals. Future research can accordingly select either a small spacing 4-spot electrode configuration for a single artery sensing or a band electrode configuration for overall pulsatile arteries sensing. A more accurate estimation of blood volume change and pulse wave analysis (PWA) could help to develop cuffless blood pressure measurement (BPM).

Background:The prescribing of injectable end-of-life anticipatory medications ahead of possible need is recommended best practice. The financial costs of these medications have been little studied.Aim:To identify the costs of anticipatory medications prescribed, used and not used for patients approaching the end-of-life at home and in residential care.Design:Retrospective observational study using general practitioner and community nursing clinical records.Setting/participants:Data were collected from eleven general practitioner practices using the records of the 30 most recent deaths per practice. Patients were aged 18+ and died between 2017 and 2019 from any cause except trauma, sudden death or suicide.Results:Anticipatory medications were prescribed to 167/329 patients, of which 164 were included in the analysis. Costs (GBP) were analysed both at patient-level and drug-level. Median anticipatory prescription cost was £43.17 (IQR: £38.98–£60.47, range £8.76–£229.82). Median administered (used) drug cost was £2.16 (IQR: £0.00–£12.09, range £0.00–£83.14). Median unused (wasted) drug cost was £41.47 (IQR: £29.15–£54.33, range £0.00–£195.36). Prescription, administered and unused costs were significantly higher for the 59 patients prescribed an anticipatory syringe driver. There were wide variations in the unused costs of individual drugs; Haloperidol and Cyclizine contributed 49% of total unused costs.Conclusion:The costs of prescribed and unused anticipatory medications were higher than previously reported but remain modest. Usage of prescriptions was lower than previously documented. There may be scope to reduce the quantity of vials that are routinely prescribed without adversely affecting care; further research is needed to investigate this possibility.

Background:Alfaxalone is commonly used in veterinary anesthesia for the induction of general anesthesia (GA) in dogs. However, it has been associated with dose-dependent cardiovascular depression. Therefore, the administration of liposoluble, intravenous (IV)-administered injectable induction agents, such as alfaxalone, is recommended to be based on the dog’s lean body mass (LBM).Aim:To determine the influence of body condition score (BCS) on IV alfaxalone dose requirements to achieve endotracheal intubation in dogs.Methods:Prospective clinical study. A group of 34 dogs undergoing GA for diagnostic and/or surgical procedures, body weight (BW) > 4 kg, BCS > 2, age 1–14 years, American Society of Anesthesiologists (ASAs) classification I–III. Dogs were allocated to two different groups according to their BCS: non-overweight group (NOW) BCS: 3–5 and over-weight group (OW) BCS: 6–9. All dogs were premedicated IV with methadone 0.2 mg kg−1, and anesthesia was induced by a slow IV infusion of alfaxalone at 1 mg kg−1 minute−1, delivered with a syringe driver, until loss of jaw tone and no/minimal gagging reflex sufficient to allow endotracheal intubation was achieved. The total dose of alfaxalone and the occurrence of post-induction apnoea were recorded.The Shapiro–Wilk test was performed to test for normality. A Chi-square test was performed to compare the incidence of post-induction apnoea between groups, and the Mann–Whitney U test was performed to compare the induction dose of alfaxalone between groups. A p-value < 0.05 was considered statistically significant.Results:The mean dose ± standard deviation of alfaxalone in NOW was 2.18 ± 0.59 mg kg−1, and in OW, it was 1.63 ± 0.26 mg kg−1 (p = 0.002). The sedation score did not differ between groups. Postinduction apnoea (PIA) occurred in 6 of 17 animals in NOW and 15 of 17 in OW (p = 0.002).Conclusion:The dose of IV alfaxalone per kg of total body mass required to achieve endotracheal intubation was lower in overweight dogs, suggesting that LBM should be considered when calculating IV anesthetic doses. The incidence of post-induction apnoea was higher in overweight/obese dogs with alfaxalone administered at a rate of 1 mg kg−1 minute−1.

BackgroundInfusion failure may have severe consequences for patients receiving critical, short–half-life infusions. Continued interruptions to infusions can lead to subtherapeutic therapy.ObjectiveThis study aims to identify and rank determinants of the longevity of continuous infusions administered through syringe drivers, using nonlinear predictive models. Additionally, this study aims to evaluate key factors influencing infusion longevity and develop and test a model for predicting the likelihood of achieving successful infusion longevity.MethodsData were extracted from the event logs of smart pumps containing information on care profiles, medication types and concentrations, occlusion alarm settings, and the final infusion cessation cause. These data were then used to fit 5 nonlinear models and evaluate the best explanatory model.ResultsRandom forest was the best-fit predictor, with an F1-score of 80.42, compared to 5 other models (mean F1-score 75.06; range 67.48-79.63). When applied to infusion data in an individual syringe driver data set, the predictor model found that the final medication concentration and medication type were of less significance to infusion longevity compared to the rate and care unit. For low-rate infusions, rates ranging from 2 to 2.8 mL/hr performed best for achieving a balance between infusion longevity and fluid load per infusion, with an occlusion versus no-occlusion ratio of 0.553. Rates between 0.8 and 1.2 mL/hr exhibited the poorest performance with a ratio of 1.604. Higher rates, up to 4 mL/hr, performed better in terms of occlusion versus no-occlusion ratios.ConclusionsThis study provides clinicians with insights into the specific types of infusion that warrant more intense observation or proactive management of intravenous access; additionally, it can offer valuable information regarding the average duration of uninterrupted infusions that can be expected in these care areas. Optimizing rate settings to improve infusion longevity for continuous infusions, achieved through compounding to create customized concentrations for individual patients, may be possible in light of the study’s outcomes. The study also highlights the potential of machine learning nonlinear models in predicting outcomes and life spans of specific therapies delivered via medical devices.

[13N]Ammonia is one of the most commonly used Positron Emission Tomography (PET) radiotracers in humans to assess myocardial perfusion and measure myocardial blood flow. Here, we report a reliable semi-automated process to manufacture large quantities of [13N]ammonia in high purity by proton-irradiation of a 10 mM aqueous ethanol solution using an in-target process under aseptic conditions. Our simplified production system is based on two syringe driver units and an in-line anion-exchange purification for up to three consecutive productions of ~30 GBq (~800 mCi) (radiochemical yield = 69 ± 3% n.d.c) per day. The total manufacturing time, including purification, sterile filtration, reformulation, and quality control (QC) analyses performed before batch release, is approximately 11 min from the End of Bombardment (EOB). The drug product complies with FDA/USP specifications and is supplied in a multidose vial allowing for two doses per patient, two patients per batch (4 doses/batch) on two separate PET scanners simultaneously. After four years of use, this production system has proved to be easy to operate and maintain at low costs. Over the last four years, more than 1000 patients have been imaged using this simplified procedure, demonstrating its reliability for the routine production of large quantities of current Good Manufacturing Practices (cGMP)-compliant [13N]ammonia for human use.

The present study describes an epidemiological investigation into a carbapenem-resistant Acinetobacter baumannii (CRAB) outbreak, which had occurred in a neonatal intensive care unit (NICU), and the subsequent strengthening of infection control interventions. Upon the onset of the outbreak, existing infection control interventions were reviewed, and a set of containment measures were instituted. All CRAB isolates were characterized in terms of antimicrobial susceptibility testing and their genetic relatedness. The investigation process identified gaps within the NICU’s existing infection control measures, which had likely resulted in the outbreak. CRAB was isolated from nine preterm infants: five colonized and four infected. All five colonized patients were discharged well. However, three out of four of the infected infants died. Outbreak investigation and genomic subtyping of environmental swabs revealed that mini syringe drivers shared between patients and a sink in the milk preparation room had served as CRAB reservoirs with possible transmission via the hands of healthcare workers. Implementation of immediate actions such as reinforcement of hand hygiene practices, intensified environmental cleaning, geographical cohorting, reviewing of milk handling practices and sink management protocol had resulted in no further CRAB isolation. The CRAB outbreak in the NICU underlines the importance of consistent compliance with infection-control interventions. Integration of epidemiological and microbiological data, together with comprehensive preventive measures, successfully brought the outbreak to a halt.

1University of Nottingham School of Medicine, Nottingham, UK 2Paediatric Critical Care Unit, Nottingham Children's Hospital, Nottingham UK 3Pharmacy Department, Nottingham Children's Hospital, Nottingham UK

Objectives:The coronavirus 19 disease (COVID-19) pandemic has led to a renewed focus on end-of-life care. The majority of COVID-19 deaths occur in hospital, with patients cared for by generalists and hospital specialist palliative care teams (HSPCTs). This project aims at exploring the potential influences of HSPCTs on end-of-life care in COVID-19.Methods:A retrospective observational study was carried out by exploring four end-of-life care themes in a Scottish hospital population who died from COVID-19. Comparison was made between cohorts seen by HSPCTs versus generalist clinicians.Results:Analysis of 119 patients across NHS Greater Glasgow and Clyde (NHSGGC) health board demonstrated that COVID-19 patients seen by HSPCTs were more likely to be younger (median 77 vs. 81 years; p = 0.02), have a cancer diagnosis (21.7% vs. 5.4%; p = 0.01), die sooner after admission (median four vs. six days; p < 0.01), and be commenced on a syringe driver (89.1% vs. 42.5%; p < 0.01). Differences detected across four end-of-life care themes comparing HSPCTs with generalist teams were minimal with documentation and prescribing in keeping with available guidance.Conclusion:Consistencies in end-of-life care observed across NHSGGC cohorts draw attention to the potential wider impact of HSPCT roles, including education, guideline development, and mentoring. Understanding such diverse effects is important to support funding and development of HSPCTs. Further research is required to better quantify the impact and heterogenous influences of HSPCTs in general.

Sporadic Creutzfeldt-Jakob Disease (sCJD) is a rare, rapidly progressive neurological disorder, that is ultimately fatal. We have written a case report on a patient recently admitted to the hospice having been diagnosed 2 days earlier with sCJD. Unfortunately, she had an aggressive form and deteriorated very rapidly 10 days post admission. Our focus was on symptom control and supportive care, for both patient and family, with psychological and spiritual support a vital component of this. Of her multitude of symptoms, the most challenging were the fluctuating episodes of severe emotional distress, agitation and restlessness. Non-pharmacological approaches proved extremely helpful, but as the disease progressed, we found that in addition to this, a combination of midazolam, levomepromazine and morphine proved the most effective in her syringe driver. All of this care took place within the context of a holistic, multi-disciplinary team, vital for managing the rapidly changing symptoms of this complex disease and its effect on both patient and family. Given its rare nature, there is only limited research on the palliative care aspects of managing terminal sCJD. We therefore hope that by sharing our experience, this case report may prove helpful.