In this randomized clinical study, we compared the intubation success rates of the intubating laryngeal mask airway with the GlideScope® in patients with normal airways. The primary hypothesis was that the intubating laryngeal mask airway was equally effective as the GlideScope® in terms of successful intubation times.

Sixty ASA I and II adult patients undergoing elective gynaecological surgery were randomly allocated into either the intubating laryngeal mask airway group or the GlideScope® group. After a standard anaesthetic intravenous induction, orotracheal intubation was performed. Time taken for successful tracheal intubation, ease of device insertion, difficulty of tracheal intubation, manoeuvres needed to aid tracheal intubation, number of intubation attempts, haemodynamic changes every 2.5 min interval for 5 min and complications during tracheal intubation were recorded.

Time to successful intubation was longer (mean 68.4 s ± 23.5 vs. 35.7 s ± 10.7; P < 0.05), mean difficulty score was higher (mean 16.7 ± 16.3 vs. 7.3 ± 13.1; P < 0.05) and more intubation attempts were required in the intubating laryngeal mask airway group.

The GlideScope® improved intubation time and difficulty score for tracheal intubation when compared with the intubating laryngeal mask airway in our patients. Blind intubation through the intubating laryngeal mask airway offers no advantages over the GlideScope® in patients with normal airways. Despite its limitations, the intubating laryngeal mask airway is a valuable adjunct, especially in cases of difficult airway management when it can provide ventilation in between intubation attempts.

Tracheostomy is one of the most common procedures in intensive care units worldwide. In this study we aimed to compare three different tracheostomy techniques with respect to duration of procedure and complications.

One hundred and thirty patients requiring endotracheal intubation for more than 10 days due to acute respiratory distress syndrome, infections or cerebrovascular events were consecutively selected to undergo the percutaneous dilatational tracheostomy technique (PDT n = 44), the guide-wire dilating forceps technique group (GWDF n = 41) or the PercuTwist technique (n = 45). The time taken to perform the procedure (skin incision to successful placement of tracheostomy tube) and complications were recorded.

The operating times were found to be 9.9 ± 1.1, 6.2 ±1.4 and 5.4 ± 1.2 min in PDT, GWDF and PercuTwist groups, respectively. The duration of the procedure was significantly shorter in the PercuTwist group as compared to the percutaneous dilatational tracheostomy (P < 0.01) and guide-wire dilating forceps (P < 0.05) groups. During postoperative bronchoscopy, eight cases of longitudinal tracheal abrasion (four in the PDT group, two in the GWDF group and two in the PercuTwist group), two cases of posterior tracheal wall injury (one in PDT and one in GWDF) and one case of tracheal ring rupture in the PDT group were seen.

Percutaneous tracheostomy techniques have their own advantages and complications. PercuTwist, a new controlled rotating dilatation method, was associated with minimal complications, appears to be easy to perform and a practical alternative to percutaneous dilatational tracheostomy and guide-wire dilating forceps techniques.

We surveyed delegates at the Group of Anaesthetists in Training (UK) meeting to investigate evidence of a training-gap (number of fibreoptic intubations believed to bestow competence vs. number actually performed).

Questionnaires were distributed to and collected from delegates in person. Questions covered six areas, including experience of fibreoptic intubation and cricothyrotomy, fibreoptic intubation as a specialist skill and ethical issues.

We received 221 replies (76%). All trainees believed competence to be achievable with 10 intubations (interquartile range (IQR) 10–20); the median number performed was 2 (IQR 0–4). This was statistically significant for the groups senior house officers, 1st and 2nd year registrars and 3rd and 4th year registrars; P < 0.0001. Many final year trainees (12/20, 60%) also failed to achieve their competency target. Few trainees had seen or performed any cricothyrotomies (medians 0, IQRs 0–1 and 0–0). Most (195/208, 94%) believed that fibreoptic intubation was a core skill and 199/212 (94%) believed that all should be competent by completion of training. Ten percent (n = 208) felt it unethical to perform an awake training intubation with full consent and 10% believed it acceptable without explanation. Most (82.7%) would fibreoptically intubate an asleep patient (requiring intubation) without consent.

Trainees reported a gap between their perception of competence and achievement in awake fibreoptic intubation. Simple and complex simulations and structured training programmes may help. Anaesthetists must address the ethics of clinical training in advanced airway management.

Delayed recovery of cognitive function is a well-recognized phenomenon in older patients. The potential for the volatile anaesthetic used to contribute to alterations in postoperative cognitive function in older patients following minor surgical procedures has not been determined. We compared emergence from isoflurane and sevoflurane anaesthesia in older surgical patients undergoing urological procedures of short duration.

Seventy-one patients, 60 yr of age or older, undergoing anaesthesia expected to last less than 60 min for ambulatory surgery, were randomly assigned to receive isoflurane or sevoflurane. A standardized anaesthetic protocol was used, with intravenous fentanyl 1 μg kg−1 and propofol 1.5–2.0 mg kg−1 administered to induce anaesthesia. Anaesthesia was maintained with either sevoflurane or isoflurane in 65% nitrous oxide and oxygen. Early and intermediate recovery times were recorded. The mini mental state examination and digit repetition forwards and backwards were administered at baseline, and at 1, 3 and 6 h postoperatively, to assess cognitive function.

There were no between-group differences in (sevoflurane vs. isoflurane, mean ± standard error of the mean) times to removal of the laryngeal mask airway (7.7 ± 0.6 vs. 7.1 ± 0.4 min), verbal response time (10.1 ± 0.7 vs. 9.9 ± 0.7 min) and orientation (12.1 ± 0.7 vs. 12.1 ± 0.7 min). Intermediate recovery, as measured by time to readiness for discharge from the post anaesthesia care unit (44.9 ± 1.5 vs. 44.3 ± 1.5 min), was similar in the two groups. Postoperative indices of cognitive function and attention were comparably reduced at 1 h, but returned to baseline in both groups at 6 h.

Isoflurane and sevoflurane anaesthesia resulted in similar clinical and neurocognitive recovery profiles in older patients undergoing ambulatory surgical procedures of short duration.

Preoperative oral dextromethorphan and intravenous clonidine attenuate arterial pressure and heart rate increases during tourniquet inflation under general anaesthesia. The effect of preoperative oral clonidine on these variables has not been investigated.

We designed this study to compare the effect of preoperative oral dextromethorphan or clonidine on haemodynamic changes during tourniquet inflation in 75 patients undergoing lower limb surgery under general anaesthesia. Patients were randomly assigned into three groups: dextromethorphan 30 mg (n = 25), clonidine 3 μg kg−1 (n = 25) and placebo (n = 25). Anaesthesia was maintained with isoflurane 1.2% and N2O 50% in oxygen with endotracheal intubation. Dextromethorphan, clonidine or placebo was given orally in a double-blinded fashion 90 min before induction of anaesthesia. Systolic, diastolic and mean arterial pressure and heart rate were measured at 0, 30, 45, 60 min after the start of tourniquet inflation, before tourniquet release and 20 min after tourniquet deflation.

Systolic, diastolic and mean arterial pressure were significantly lower in the clonidine group compared with control after 45, 60 min tourniquet inflation and before tourniquet release (P < 0.05). Twenty minutes after deflation, diastolic and mean arterial pressure in the control group were still increased and significantly higher compared with the clonidine group (P < 0.05). Development of more than a 30% increase in systolic arterial pressure during tourniquet inflation was more frequent in the control group than in the other groups.

Preoperative oral clonidine 3 μg kg−1 significantly prevented tourniquet-induced systemic arterial pressure increase in patients under general anaesthesia better than oral dextromethorphan.

In human beings, pain and taste perception are two major sensory inputs. We investigated whether increasing bitter taste sensitivity would increase intensity or incidence of pain associated with propofol, and whether there is a relationship between bitter sensitivity and venepuncture pain.

One hundred (50 males, 50 females) American Society of Anesthesiologists Grade I adults undergoing elective surgery were included in this study. Determination of the taste thresholds employed a series of propylthiouracil solutions. The filter paper disk method was used to measure the taste threshold. A 20-G intravenous (i.v.) cannula was inserted in the dorsum of the non-dominant hand. Venepuncture pain was assessed by using a numerical rating scale (NRS; 0, no pain and 10, extreme pain). Propofol 10 mL (100 mg) was injected over 30 s. Assessment of pain with i.v. propofol was made using a 4-point scale: 0, no pain; 1, mild pain; 2, moderate pain; 3, severe pain.

The NRS score of venepuncture pain was 2.8 ± 1.5. Sixty patients had pain during propofol injection. There was statistically significant correlation between bitter sensitivity and propofol injection pain, and between bitter sensitivity and venepuncture pain (P < 0.05).

We conclude that increased bitter taste sensitivity correlates with increased intensity or incidence of propofol injection pain and NRS of venepuncture pain.

Gabapentin and local anaesthetics may decrease postoperative pain and analgesic needs. The aim of the study was to investigate the effect of the combination of these drugs on the analgesic needs as well as on acute and late pain after abdominal hysterectomy.

Sixty patients undergoing abdominal hysterectomy were randomly assigned to receive postoperatively oral gabapentin 400 mg 6 hourly for 7 days plus continuous wound infusion of ropivacaine 0.75% for 30 h or placebo capsules identical to those of gabapentin for 7 days and continuous wound infusion of normal saline for 30 h. Morphine consumption (PCA) for 48 h, paracetamol 500 mg plus codeine 30 mg (Lonalgal® tablets) intake on days 3–7, visual analogue pain scores at rest and after cough during the first 7 postoperative days, the need for analgesics at home and the presence and incidence of pain after 1 month were recorded.

The treatment group consumed less cumulative morphine over the first 48 h (31 ± 13.2 mg vs. 50 ± 20.5 mg in controls, P < 0.001) and less Lonalgal® tablets on days 3–7 (z = 2.54, P = 0.011). The visual analogue score values at rest and after cough did not differ between the groups during the first 7 postoperative days. One month postoperatively, fewer patients in the treatment group experienced pain due to surgery than in the control group (17/27 vs. 21/24, P = 0.045).

Gabapentin and continuous wound infusion with ropivacaine 0.75% decreased analgesic needs and late pain in patients undergoing abdominal hysterectomy.

Atrial and brain natriuretic peptide, synthesized by cardiac myocytes, are mediators secreted secondary to cardiac volume expansion and increased filling pressure. The study was designed to assess serum concentration of atrial and brain natriuretic peptide in patients undergoing endonasal sinus surgery receiving controlled hypotension.

We studied 45 patients without cardiovascular history, scheduled for elective endonasal sinus surgery. Patients were allocated to one of three groups: controlled hypotension was induced either by using esmolol (n = 15) or sodium nitroprusside (n = 15) with a mean arterial pressure of 50–55 mmHg. In the control group (n = 15), mean arterial pressure was adjusted to 70–80 mmHg. Atrial and brain natriuretic peptides were measured preoperatively (T1), at the end of surgery (T2), 2 h (T3), 24 h (T4) and 48 h (T5) postoperatively.

Preoperative atrial and brain natriuretic peptide plasma levels were within normal ranges and similar between all groups. Patients treated with esmolol (atrial natriuretic peptide: 2.46 ± 0.75 μg mL−1; brain natriuretic peptide: 4.34 ± 3.06 μg mL−1) and sodium nitropusside (atrial natriuretic peptide: 2.48 ± 0.92 μg mL−1; brain natriuretic peptide: 4.49 ± 3.21 μg mL−1) showed significantly lower concentrations of atrial and brain natriuretic peptide at T2 and T3 compared with controls (atrial natriuretic peptide: 5.31 ± 2.32 μg mL−1; brain natriuretic peptide: 13.26 ± 8.98 μg mL−1, P < 0.01) as well as a reduction in blood loss and duration of surgery.

Controlled hypotension decreases the release of natriuretic peptides in cardiovascular healthy patients. This effect may be contributed to by changes in cardiac filling pressure due to lower systemic resistance and diminished perfusion pressure.

The purpose of this study was to examine the effects of intravenous dexmedetomidine on the duration of bupivacaine-induced epidural anaesthesia and level of wakefulness and the respective side-effects.

Sixty ASA I–II patients were included in the study. Consecutive patients were allocated to groups according to the last digit (odd/even) of their admission numbers. All patients had epidural anaesthesia with bupivacaine 0.5% performed by the same experienced anaesthesiologist. In the first group, the patients were administered intravenous dexmedetomidine infusion just after the epidural block and continued during the operation, while those in the second group were administered physiologic saline infusion at the same amount and duration.

The recovery time of sensory block was significantly longer in the first group. The bispectral index values were lower in the first group than in the second. Also, heart rate was significantly lower in Group I than in Group II. Regarding side-effects, shivering was significantly less frequent in the first group, whereas there was a significant increase in the requirement of atropine in the first group as dexmedetomidine caused bradycardia.

Intravenous administration of dexmedetomidine prolonged the duration of epidural anaesthesia, provided sedation and had few side-effects.

This prospective, double-blind, randomized, placebo-controlled study was designed to determine the efficacy of dexmedetomidine compared with lidocaine in reducing the pain of propofol and rocuronium injection pain.

One hundred and fifty patients, scheduled for elective surgery with general anaesthesia, were divided into five groups: saline (Group 1), dexmedetomidine 0.25 μg kg−1 (Group 2), lidocaine 0.5 mg kg−1 (Group 3), dexmedetomidine 0.25 μg kg−1 plus lidocaine 0.25 mg kg−1 (Group 4) or dexmedetomidine 0.25 μg kg−1 plus lidocaine 0.5 mg kg−1 (Group 5) were administered at a rate of 0.5 mL s−1 after tourniquet application. The occlusion was released after 1 min and 5 mL of propofol was injected over 20 s. Pain was evaluated by use of a 10-point verbal analogue scale. Then, the rest of the induction dose of propofol, 3 mL of saline bolus and 0.6 mg kg−1 of rocuronium, was injected. The response to injection of rocuronium was assessed with a four-point scale (0–3).

Groups 1 and 2 were found to have higher propofol injection pain scores than Groups 3, 4 and 5 (P < 0.05). When the study groups were compared according to the overall incidence of withdrawal movements due to rocuronium (⩾1 response) in Groups 1, 2, 3, 4 and 5, they were different (86.7%, 60%, 36.7%, 50% and 40%, respectively) (P < 0.05). Except Group 1, there was no significant difference between the groups according to incidence of withdrawal movement after rocuronium injection (P = 0.325).

Pretreatment with dexmedetomidine is not effective in reducing injection pain of propofol, but may attenuate the hand withdrawal associated to rocuronium, as lidocaine does.

To compare intubation conditions and time-course of action of rocuronium and mivacurium for day case anaesthesia.

Fifty ASA I or II patients were enrolled. Anaesthesia was induced with propofol using a target controlled infusion system (target 6–8 μg mL−1) and sufentanil (0.25 μg kg−1). It was maintained with propofol (target 3.5–4.5 μg mL−1) and 50% nitrous oxide in oxygen. Muscle relaxation was achieved with either mivacurium (0.15 mg kg−1) or rocuronium (0.3 mg kg−1). Neuromuscular transmission was monitored and recorded continuously by acceleromyography using a TOF-WATCH SX (Biometer™/; Denmark) with supramaximal train-of-four stimulation of the ulnar nerve. Tracheal intubation was carried out by an experienced anaesthetist blinded to the type of the muscle relaxant. Intubation conditions were evaluated according to a standard scheme (ease of laryngoscopy, position of vocal cords, airway reaction and limb movements).

Intubation conditions were good or excellent for both mivacurium 0.15 mg kg−1 (good = 8%; excellent = 92%) and rocuronium 0.3 mg kg−1 (excellent = 100%). Times to maximum blockade and clinical duration were not different.

There is no significant difference between mivacurium and rocuronium concerning the onset and the recovery of muscle relaxation. Rocuronium is an alternative to mivacurium for short procedures, without the risk of unexpected prolonged relaxation due to a possible defect in plasma cholinesterase.

Serum creatine kinase and myoglobin elevation has been described involving muscle manipulation after surgery and also after bariatric, urologic and gynaecologic procedures. It encompasses a wide range of severity, reflecting in the worst cases true rhabdomyolysis. We occasionally noted creatine kinase elevations after intracranial neurosurgery, an occurrence that has not yet been described. To assess whether the issue of postoperative muscle enzyme elevation is relevant to neurosurgery, we prospectively measured serum creatine kinase and myoglobin in a series of neurosurgical patients submitted to craniotomy.

We studied 30 patients aged 22–69 yr submitted to craniotomy. Blood samples were taken prior to the procedure, at the end of anaesthesia and on the first, second and third postoperative days. Blood was checked for creatine kinase, myoglobin, lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen, creatinine and serum electrolytes. We recorded the patient’s age, sex, height, weight and body mass index. Throughout surgery, we recorded the highest and the lowest body temperature and sampled the mean arterial pressure at 5 min intervals. We performed backwards stepwise logistic regression analysis to identify the elements that best correlate with the development of cell muscle damage.

On the first postoperative day creatine kinase peaked from baseline (305 (107–1306) UI L−1 vs. 59 (42–94) UI L−1; P < 0.001) while myoglobin rose significantly from baseline to the end of surgery (70 (42–147) ng mL−1 vs. 36 (30–44) ng mL−1; P = 0.002). Logistic regression showed that length of surgery was the only factor clearly influencing peak creatine kinase (P < 0.001; R2 0.7) and myoglobin (P = 0.011; R2 0.41) concentration.

Creatine kinase and myoglobin elevation may occur after intracranial neurosurgery. In our series, length of surgery was a risk factor.