Summary

Background and objective: The electroencephalographic Narcotrend Index (NI) is a measure of the hypnotic component of general anaesthesia. The purpose of this study was to evaluate the impact of Narcotrend guidance on propofol consumption and emergence times in children receiving total intravenous anaesthesia with propofol and remifentanil. Methods: Thirty children, aged 1–11 yr, scheduled for paediatric urological surgery were enrolled. Remifentanil was given to all patients at a constant infusion rate of 0.3 μg kg−1 min−1 throughout anaesthesia. Patients were randomly allocated to receive a continuous propofol infusion adjusted either according to a conventional clinical practice (Group C: n = 15) or guided by Narcotrend monitoring (Group NI: n = 15; target NI 60 ± 5). All patients were connected to the Narcotrend Monitor, but in Group C the anaesthetist was blinded to the screen of the monitor. Propofol consumption (mg kg−1 h−1) and emergence times (min) were the primary and secondary outcome measures. Results: Propofol consumption (median [inter-quartile range]) was significantly lower in Group NI compared to Group C (NI: 7.0 [6.4–8.2] vs. C: 9.3 [8.3–11.0] mg kg−1 h−1; P < 0.001), whereas Log-Rank-analysis revealed no intergroup difference in emergence times (Group NI: mean [95% confidence interval (CI)] 12.8 [11.2–14.4] min; Group C: 16.4 [12.6–20.2] min; P = 0.10). Haemodynamic variables remained stable within age-related limits, and there were no observations of adverse events, especially no clinical signs of intraoperative awareness in any patient. Conclusion: Narcotrend monitoring for guidance of propofol/remifentanil anaesthesia in children results in reduced propofol consumption compared to a conventional clinical practice.

Summary

Background and objective: Previous studies mainly conducted on elective patients recommend doses of 0.9–1.2 mg kg−1 rocuronium to obtain comparable intubation conditions with succinylcholine 1.0 mg kg−1 after 60 s during a rapid-sequence induction. We decided to compare the overall intubating conditions of standard doses of rocuronium 0.6 mg kg−1 and succinylcholine 1.0 mg kg−1 during a strict rapid-sequence induction regimen including propofol and alfentanil. Methods: Male and female patients (ASA I–III) older than 17 yr scheduled for emergency abdominal or gynaecological surgery and with increased risk of pulmonary aspiration of gastric content were randomized to a rapid-sequence induction with succinylcholine 1.0 mg kg−1 or rocuronium 0.6 mg kg−1. Patients with a predicted difficult airway were excluded. A senior anaesthesiologist ‘blinded’ for the randomization performed the intubation 60 s after injection of the neuromuscular blocker. Intubating conditions were evaluated according to an established guideline. Tracheal intubation not completed within 30 s was recorded as failed. Results: 222 patients were randomized. Three patients had their operation cancelled and 10 did not fulfil the inclusion criteria. Clinically acceptable intubation conditions were present in 93.5% and 96.1% of patients in the succinylcholine group (n = 107) and the rocuronium group (n = 102), respectively (P = 0.59). Conclusions: During a rapid-sequence induction with alfentanil and propofol, both rocuronium 0.6 mg kg−1 and succinylcholine 1.0 mg kg−1 provide clinically acceptable intubation conditions in 60 s in patients scheduled for emergency surgery. Under the conditions of this rapid-sequence induction regimen rocuronium may be a substitute for succinylcholine.

Summary

Background and objective: Staff attitude plays a pivotal role in quality management. The objective of the present study was to further define how interdisciplinary emergency hospital staff experience their daily work and the extent to which the professional speciality and training of an individual influences his/her assessment of multiple-trauma team performance. Methods: The clinical staff involved in multiple-trauma emergency management of a university hospital was asked to answer a confidential questionnaire. Factorial analysis was used to identify 8 major dimensions from a total of 53 items. Results: The questionnaire was returned by 128 team members. All professional groups were most dissatisfied with the dimensions ‘education and training’, ‘work sequence between specialities’ and ‘communication between specialities’. Assessment of the quality of in-hospital emergency-trauma management differed significantly between professional specialities (ANOVA, F = 5.2; P = 0.028); surgeons gave the highest ratings for all but one dimension. Having taken an Advanced Trauma Life Support (ATLS®) course influenced significantly the total rating of multiple-trauma treatments of anaesthetists and surgeons (F = 5.5; P = 0.024). Conclusions: The perceptions of interdisciplinary trauma team members without the completion of an ATLS® training course were that they did not communicate enough with each other and that there were differences between their expectations and reality. The differences and the communication deficits were overcome in team members who had passed an ATLS® course.

Summary

Background and objective: In our algorithm for management of the anticipated difficult airway the induction agent (etomidate) is administered after the tip of the fibreoptic is placed in the trachea but before the tube is advanced over it. In a previous investigation we demonstrated the safety of this method. Due to its popularity as an induction agent, some would like to replace etomidate with propofol. However, because rapid recovery of spontaneous breathing is crucial with this technique, substitution might not be advisable. We compared the speed of recovery of spontaneous breathing after fibreoptic intubation between etomidate and propofol. Methods: In this prospective, randomized, double-blind study we used either 0.2 mg kg−1 etomidate or 2 mg kg−1 propofol for induction. Our technique of nasotracheal fibreoptic intubation consists of using fentanyl, cocaine instillation into the lower nasal canals, cricothyroid injection of lidocaine, performing bronchoscopy, administration of etomidate and advancing the tube after loss of consciousness. We measured time to loss of consciousness, time to recovery of spontaneous breathing, lowest bispectral index value and time to lowest value. Results: Time to loss of consciousness did not differ. The time to recovery of spontaneous breathing differed significantly: the median time (interquartile range [range]) for etomidate was 81 s (62–102 [0–166]), and for propofol 146 s (95–260 [65–315]); P = 0.001. The lowest bispectral index values were not different. The time of the lowest bispectral index values differed significantly: for etomidate 58 s (51–68 [38–100]), and for propofol 90 s (52–125 [38–172]); P = 0.015. Conclusion: For nasotracheal fibreoptic intubation, where the tube is advanced after induction of anaesthesia, we still recommend etomidate because spontaneous breathing recovers faster than with propofol.

Summary

Background and objective: Effective and early treatment of postoperative pain and nausea have become pivotal for the early discharge of patients after tonsillectomy. Opioid-based analgesia is standard practice but the use of non-steroidal anti-inflammatory drugs is discouraged due to their platelet inhibiting properties. The cyclo-oxygenase-2 selective non-steroidal anti-inflammatory drugs are effective analgesics and do not affect platelet function. We hypothesized that premedication with cyclo-oxygenase-2 selective non-steroidal anti-inflammatory drug in addition to paracetamol would provide effective analgesia and decrease opioid consumption during early recovery from tonsillectomy. Methods: In a randomized, placebo-controlled study of adult tonsillectomy patients (n = 40) one group (R-group; n = 20) was premedicated with paracetamol 1.5 g and rofecoxib 50 mg and a control group (P-group; n = 20) was premedicated with paracetamol 1.5 g and placebo. Morphine was used as rescue medication. Postoperative (24 h) pain scores (0–10), morphine consumption as well as intraoperative blood loss were recorded. Results: We found no overall difference in pain scores between the groups but significantly more patients in the placebo group had pain scores >5 within the first 8 h. The rofecoxib group consumed less morphine during the first 12 h. A lower intraoperative blood loss was observed in the rofecoxib group. Conclusion: Our results suggest an early although clinically minor analgesic benefit of the addition of a cyclo-oxygenase-2 selective non-steroidal anti-inflammatory drug to paracetamol as premedication for adult tonsillectomy.

Summary

Background and objective: Postoperative nausea and vomiting (PONV) is a frequent and unpleasant experience that may increase postoperative complications and costs. For surgical procedures with a high risk of PONV, prevention is preferable to treatment. In this study, the authors explore the dose–response relationship between granisetron administered just prior to the end of surgery and post-operative nausea and vomiting in patients undergoing abdominal hysterectomy. Methods: This was a randomized, double-blind, placebo-controlled, pilot study of post-operative nausea and vomiting prevention. Patients undergoing elective open abdominal hysterectomy requiring general anaesthesia received a single dose of granisetron 0.1, 0.2 or 0.3 mg or placebo administered approximately 15 min prior to the end of surgery. The primary efficacy end-point was the proportion of patients with no vomiting in the 0–6 h interval following medication administration. No inferential statistics were planned. Results: The proportion of patients with no vomiting episode in the 0–6 h interval after administration of study medication was higher in each granisetron treatment group (>90%) than in the placebo group (77%). Proportions of patients with no vomiting episodes in the 0–24 h interval were similar across treatment groups. Results of analyses of proportions of patients with no moderate or severe nausea episodes, proportions of those requiring rescue medication and times to first use of rescue medication suggested a treatment effect of granisetron relative to placebo in both the 0–6 and 0–24 h intervals. Similar proportions of patients in each treatment group reported at least one adverse event. Conclusions: Granisetron at doses of 0.1, 0.2 and 0.3 mg administered just prior to the end of surgery suggested a trend of improved efficacy compared to placebo in preventing postoperative nausea and vomiting in the first 6 h after abdominal hysterectomy. This pilot study did not identify a dose–response relationship.

Summary

Background and objective: We have investigated the concentrations of epinephrine, norepinephrine, vasopressin and angiotensin converting enzyme activity to explore the role of these mediators in the neuroendocrine response to laryngoscopy and tracheal intubation. Methods: One hundred (50 male, 50 female) ASA I patients aged 20–50 yr (mean ± SEM; 35.59 ± 0.99) were included in the study. They were undergoing elective surgery under standard anaesthesia induction and maintenance using tracheal intubation. Plasma concentrations of epinephrine, norepinephrine and vasopressin as well as plasma angiotensin converting enzyme activity were determined at four time points, before (T1) and after (T2) induction, and 2 (T3) and 5 min (T4) after intubation. Blood pressure and heart rate were recorded at corresponding times to reveal if any correlation existed between haemodynamic parameters and neuroendocrine response. Results: Heart rate increased after induction and intubation (P < 0.05) and decreased significantly at T4 (P < 0.05). Systolic blood pressure decreased significantly (P < 0.05) after induction and increased slightly after intubation decreasing to below baseline value (P < 0.05) at T4. Diastolic blood pressure increased slightly after intubation and decreased significantly (P < 0.05) at T4. Plasma epinephrine and norepinephrine concentrations decreased after induction and increased at T3 and T4 without reaching significance. Vasopressin concentrations increased slightly at T2 and T3 and decreased significantly at T4 (P < 0.05). Angiotensin converting enzyme activity was unaffected when compared with baseline values. Conclusions: Blood pressure, heart rate, plasma epinephrine, norepinephrine and vasopressin concentrations increased slightly in response to laryngoscopy and intubation, all returning to or below baseline 5 min later with no change in angiotensin converting enzyme activity in normotensive patients.

Summary

Background and objective: We evaluated the effect of duration of mechanical ventilation with different tidal volumes (VT) on ventilator-induced lung injury in healthy rats. Methods: Anaesthetized rats were ventilated with VT between 9 and 45 mL kg−1 for 1 or 7 h with a positive end-expiratory pressure of 2.5 cmH2O. Results: After 1 h, rats ventilated even with the highest applied VT (36 and 45 mL kg−1, resulting in average peak airway pressures of 30 ± 3 and 37 ± 4 cmH2O), had no detectable alterations in dynamic or static lung mechanics, gas exchange or pulmonary permeability, but a moderate degree of lung inflammation (neutrophil accumulation in broncho-alveolar lavage) observed in all groups. In contrast, after 3 h of ventilation, rats ventilated with the highest VT (36 and 45 mL kg−1) died from progressive circulatory failure and high-permeability pulmonary oedema, manifested by hypoxaemia, an increased alveolar–arterial protein concentration ratio and a reduced static lung compliance (mortality rate at 7 h, 62.5% and 100%). Animals with lower VT all survived and presented no changes in the measured variables. Conclusion: These results in normal rats demonstrate the preponderant effect of the duration (>3 h) of ‘aggressive’ ventilation and the cut-off value of the level of VT applied (>27 mL kg−1).

Summary

Background and objective: Recent studies have suggested that cytochrome P-450 isoenzyme 1A2 has an important role in lidocaine biotransformation. We have studied the effect of a cytochrome P-450 1A2 inhibitor, ciprofloxacin, on the pharmacokinetics of lidocaine. Methods: In a randomized, double-blinded, cross-over study, nine healthy volunteers ingested for 2.5 days 500 mg oral ciprofloxacin or placebo twice daily. On day 3, they received a single dose of 1.5 mg kg−1 lidocaine intravenously over 60 min. Plasma concentrations of lidocaine, 3-hydroxylidocaine and monoethylglycinexylidide were determined for 11 h after the start of the lidocaine infusion. Results: Ciprofloxacin increased the mean peak concentration and area under plasma concentration–time curve of lidocaine by 12% (range −6 to +46%; P < 0.05) and 26% (8–59%; P < 0.01), respectively. The mean plasma clearance of lidocaine was decreased by ciprofloxacin by 22% (7–38%; P < 0.01). Ciprofloxacin decreased the area under the plasma concentration–time curve of monoethylglycinexylidide by 21% (P < 0.01) and that of 3-hydroxylidocaine by 14% (P < 0.01). Conclusion: The plasma decay of intravenously administered lidocaine is modestly delayed by concomitantly administered ciprofloxacin. Ciprofloxacin may increase the systemic toxicity of lidocaine.