Proceedings of the Waikato Clinical Campus Biannual Research Seminar Wednesday 11 March 2020

PROCEEDINGS

Ablation of ventricular patients (inability to locate PVC Pain relief options in arrhythmias at origin in a patient with multiple labour: remifentanil different morphologies, inad- Waikato Hospital vertent aortic puncture with no PCA vs epidural Janice Swampillai,1 E Kooijman,1 M sequelae, PVC focus adjacent to Dr Jignal Bhagvandas,1 Symonds,1 A Wilson,1 His bundle, cardiogenic shock Mr Richard Foon2 1 1 1 RF Allen, K Timmins, A Al-Sinan, during anaesthesia). Endo- 1Whangarei Hospital, Whangarei; D Boddington,2 SC Heald,1 MK Stiles1 cardial ablation was done in 96 2Waikato Hospital, Hamilton. 1Waikato Hospital, Hamilton; patients and three patients also Objective 2Tauranga Hospital, Tauranga. underwent epicardial ablation Remifentanil is commonly Background (one patient underwent two used in obstetrics due to its Catheter ablation can be an epicardial procedures including fast metabolism time. It is effective treatment strategy one open chest procedure). an attractive option for IV for patients with ventricular General anaesthesia was used patient-controlled analgesia tachycardia (VT) or frequent in 46% of cases, conscious (PCA) in labour. We compared premature ventricular sedation was used in 54%. the effi cacy of IV Remifen- complexes (PVCs). The goal is to Sixty-two percent were elective tanil PCA with epidural during improve quality of life as well as procedures and 38% were labour. mortality. done acutely. The overall acute Method success rate was 91%, falling to Objectives Using a retrospective We aimed to characterise 75% at three months, 73% at six approach, we identifi ed a our population of patients who months and 68% at 12 months. total of 285 patients requiring have undergone ablation for Average procedure time was Remifentanil PCA presenting to ventricular arrhythmias over 180±64 minutes, fl uoroscopy Waikato delivery suite between the past six years, and report time 15±12 minutes, ablation the years 2017 to 2019. The outcomes of this procedure. time 22±19 minutes. The 30-day primary outcome measured complication rate post-pro- Methods was an assessment of patients cedure was 5.8%, occurring in We analysed data from requiring further epidural anal- seven patients. These compli- consecutive patients who gesia post-Remifentanil PCA. cations were two deaths, underwent VT/PVC ablation Secondary outcomes included three pericardial effusions from January 2014–February number requiring caesarean requiring pericardiocentesis, 2020. Medical and cardiac section, instrumental use and one stroke with full recovery, implantable electronic device number with a PPH or tear. This one groin haematoma which records were reviewed. was compared to 285 patients did not require intervention. Results requiring epidural analgesia. During the analysis period nine A total of 121 procedures Results patients died during follow up: were performed in 100 patients. We found 24% (68 of 285) of Mortality was 4.4% at three There were 73 males and 27 Remifentanil patients required months, 6.3% at six months, 9.1 females, mean age 60±13 years. an epidural post-PCA for further % at 12 months. The aetiology of ventricular pain relief. Of the epidural Conclusion arrhythmias was ischaemia patients, 1.75% (5 of 285) In patients with ventricular in 33 (33 males), non-isch- required a second epidural after arrhythmias, ablation is a safe aemic in 63 (38 males) and failing their fi rst (RR 13.6, 95% and feasible option to reduce mixed aetiology in four (two CI 5.57–33.22, P=0.0001, P<0.05). defi brillator therapy, hospital males). A single procedure was Nineteen percent (53 of 285) of admissions, heart failure and performed in 83 patients, 12 Remifentanil patients required mortality, but repeated proce- patients had two procedures caesarean section delivery dures are often needed. Our and fi ve had three procedures compared to 31% (89 of 285) results are comparable to inter- (17 patients had ≥1 procedure, of epidural patients (RR 0.595, national standards. giving a 14% redo rate). No 95% CI 0.442–0.802, P=0.0006, ablation was done in four P<0.05). Four percent (12 of

NZMJ 12 June 2020, Vol 133 No 1516 ISSN 1175-8716 © NZMA 105 www.nzma.org.nz/journal PROCEEDINGS

285) of Remifentanil patients itative interviews have found Aortic size index required instrument use that families appreciate the predicts survival in compared to 11.2% (32 of 285) tool and have good engagement of epidural patients (RR 0.375, with staff and services they are patients with abdominal 95% CI 0.197–0.713, P=0.0028, referred to. aortic aneurysm P<0.05). 2.8% (8 of 285) of Su-Ann Yee,1 Zoë Vincent,2 Remifentanil patients had a The psychosocial needs Andrew Hill,2 Greg Jones,3 large PPH or tear compared of cancer patients in Manar Khashram4,5 to 3.5% (10 of 285) of epidural the Waikato region 1Faculty of Medical and Health patients (RR 0.800, 95% CI Sciences, University of Auckland, 1 1 1 0.320–1.998, P=0632, P>0.05). Paul N, Blackmore TL, Chepulis L, Auckland; 2Department of Vascular 2 2 1 Conclusion Burrett V, McCleery J, Lawrenson R Surgery, Auckland City Hospital, The results of this study 1Medical Research Centre, Auckland; 3Vascular Research confi rm some Remifentanil PCA University of Waikato, Hamilton; Group, Department of Surgical patients require epidural anal- 2Cancer Psychological and Social Sciences University of Otago, 4 gesia progression in labour. The Support Service, Waikato District Dunedin; Department of Vascu- rate of instrumental delivery Health Board, Hamilton. lar Surgery, Waikato Hospital, Hamilton; 5Department of Surgery and caesarean section was Cancer is a major health University of Auckland, Auckland. almost halved in the Remifen- concern in New Zealand. A Objective tanil PCA group when compared cancer diagnosis is associated Most factors infl uencing to the epidural group. This with elevated psychosocial abdominal aortic aneurysm fi nding supports the use of distress that negatively impacts (AAA) survival are well Remifentanil PCA in labour as on quality of life. The Ministry documented, however some an alternative to epidurals. of Health (MOH) recognises predictors such as BMI have the importance of screening produced contradictory results. for psychosocial distress A randomised It is well established that and providing psychosocial controlled trial of increased AAA diameter is asso- support as part of cancer care, Harti Hauora Tamariki, ciated with increased mortality yet screening is underuti- and rupture. Our hypothesis a holistic whānau- lised, resulting in a number of was to evaluate if the effect of centred approach, on patients with unmet psycho- AAA size relative to body size social needs. We investigated the paediatrics wards has an impact on survival after the characteristics and psycho- at Waikato Hospital AAA repair. social support needs of cancer Dr Nina Scott,1 patients in the Waikato region Methods 1,2 This was a retrospective Dr Polly Atatoa-Carr, who were referred to the 2 study evaluating patients with Dr Bridgette Masters-Awatere, Cancer Psychological and 1 a threshold (>5cm) AAA from Dr Amy Jones Social Support Service (CPSSS) Auckland City Hospital and 1Waikato District Health at the Waikato District Health 2 Waikato Hospital. Multisource Board, Hamilton ; University Board (DHB) between 2016 data was used to acquire patient of Waikato, Hamilton. and 2018. Data from the CPSSS information, including body size Problem were compared with Waikato measurements close to the time Too many tamariki Māori are regional data obtained from the of surgery. Logistic regression returning to hospital within one New Zealand Cancer Register and Cox-proportional models year of admission to Waikato (NZCR). Only 6% of cancer were used to analyse the 30-day Hospital. patients in the region were mortality and late survival, Solution referred to CPSSS. Age, gender, respectively. Harti Hauora Tamariki is a ethnicity and type of cancer whānau Māori-centric multi- were all signifi cant factors Results level programme to support associated with the likelihood There were 1,060 patients, wellbeing via engagement, of receiving a referral. Patients with a median age of 75 needs assessment using a with breast, haematological and years and 77% were females. screening tool and provision head and neck cancers were AAA diameter and body size of, or navigation to wellbeing the most likely to be referred, measurements were not asso- services. as were younger patients and ciated with 30 day mortality. The median follow-up was 4.5 years. Method females. Males and Māori were We conducted a less likely to be referred. The AAA diameter was a risk for randomised-controlled trial most common reasons patients late survival (Hazard ratio [HR]: recruiting over 980 whānau sought a psychosocial referral 1.18, 95% confi dence interval with a child (aged 0–4) admitted were psychological/emotional [CI]: 1.06–1.30). Increased to the acute paediatric ward at distress, family concerns and weight, body mass index and Waikato Hospital. Half were fear of treatment. Psychosocial body surface area were all randomised into the inter- distress is present in cancer protective against mortality (HR: vention group (Harti) and half patients in the Waikato, and 0.99, CI: 0.98–0.99; HR: 0.98, CI: had usual care. the CPSSS plays a vital role in 0.5–0.99; HR: 0.46, CI: 0.25–0.83). ASI values ranged from 1.4–7cm/ Results supporting the psychosocial m2 and increased ASI was asso- Quantitative results are not needs of cancer patients. ciated with increased mortality yet available. However, qual- (HR: 1.4, CI: 1.2–1.7).

Conclusion 12.0% receiving metformin or treatment in routine clinical Patients with a large AAA and insulin. Overall, 77.6% use. and a smaller BSA had worse of patients had a metformin Method overall survival. Aortic size MPR of >0.8 and the median This study investigated two index may be a better predictor time between prescriptions drugs aimed at therapeutic of survival than using absolute was 95.4 days. The proportion targets in mechanically venti- AAA diameter and body size of patients meeting the MPR lated lungs using an isolated measurements separately. target was signifi cantly higher perfused rat lung preparation in NZ European (vs Māori (Hugo Sachs Elektronik/Harvard Metformin adherence and Pasifi ka), in those who Apparatus IPL-2). Respiratory in Waikato patients had a CVD-related hospital parameters were recorded with type 2 diabetes, admission and in older patients using ADInstruments PowerLab (all p<0.001). For patients and association and LabChart software. A who received 5–7 metformin hyperbaric model of VILI was with HbA1c levels prescriptions during the study developed. Lungs were main- Christopher Mayo,1 Lynne Chepulis,2 period (full 90-day prescribing tained at normal tidal volume Rawiri Keenan,2 Brittany Morison,2 adherence; n=1,127) 86.2% for 10 min using positive Ryan Paul,2,3 Ross Lawrenson2,3 were fully adherent with 100% pressure ventilation (between of all metformin prescriptions +3 to +15 cmH O), and then 1Faculty of Medical and Health 2 being dispensed. Prescription Sciences, University of Auckland, hyperinfl ated by increasing the Auckland; 2Waikato Medical adherence did not differ by peak end-inspiratory pressure gender, ethnicity or rurality. Research Centre, University of to +30 cmH2O for a period of Waikato, Hamilton; 3Waikato HbA1c levels were signifi - 1 hour. After this, a 90-minute District Health Board, Hamilton. cantly higher in patients measurement period was Aims and objectives with a MPR <0.8 and in those undertaken at normal negative Many patients with type 2 who were <100% adherent to breathing pressures (-2 to -12 prescriptions. diabetes (T2D) continue to have cmH2O). In treatment experi- poor glycaemic control, and Conclusions ments (n=7), the drug was added this has been associated with In general, adherence to to the recirculating perfusate poor medication adherence. The metformin was good, though seven minutes prior to lung aim of this study was to assess inequities in prescribing do hyperinfl ation. Findings were patient adherence to metformin, exist. Poorer glycaemic control compared to determine whether the gold standard fi rst-line was associated with reduced drug treatment reduced the treatment. medication adherence. severity of VILI. Methods Results Prescription, clinical and Preventing ventilator- The VILI model optimis- demographic data were induced lung injury ation was successful, with collected from the patient hyperinfl ation resulting in an 1 management system of 10 Kevin Stewart, increase in tidal volume from 2,3 different general practices Professor Anthony Phillips, 2.0–4.8mL and a corresponding 2,3 in the Waikato region for Dr Jiwon Hong, steady rise in lung weight by 3 Sept 2016–March 2018. Data Professor John Windsor 16% associated with visible were extracted for all repeat 1Principal Academic Staff Member, oedema in the lower lung lobes. metformin users aged >15 years Wintec, Hamilton; 2Applied Surgery The abnormal increased lung who had a diagnosis of T2D and Metabolism Laboratory, School weight was sustained over the of >12 months. NHI-matched of Biological Sciences, University following 90-minute normal of Auckland, Auckland; 3Surgical dispensed medication data was ventilation period as well. and Translational Research Centre, obtained from the Pharma- Department of Surgery, Univer- In the drug treatment group ceutical collection (PHARMS). sity of Auckland, Auckland the weight gain and tissue Good metformin adherence Background oedema were signifi cantly less was defi ned as a medication Mechanical ventilation is severe in the hyperinfl ation possession ratio (MPR) of >0.8 commonly used in intensive injury period and normal and was assessed 1) using care units for supplying supple- ventilation periods after drug PHARMS data alone and 2) mentary oxygen to critically ill treatment. by comparing prescribing to people. However, mechanical Conclusion dispensing information. ventilation itself often damages It was found possible to Results the recipient’s lungs. This pharmacologically attenuate the One thousand fi ve hundred damage is termed ventilator-in- severity of experimental VILI and ninety-fi ve patients were duced lung injury (VILI) and is using biochemical methods. included for analysis (median associated with poor clinical This research was supported age of 65 years; 55.5% male; outcomes. There are currently by Wintec, the University of 52.0% urban), including 49.0% no effective pharmacological Auckland and the Waikato receiving metformin only and treatments for VILI prevention Medical Research Foundation.

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