Improvement in surgical techniques, technology and perioperative assessment has dramatically simplified the anaesthetic care for elective liver resection. Patients with a non-tumorous healthy liver should only need the usual preoperative assessment. Patients with pre-existing parenchymal liver disease should be specifically assessed for gas exchange impairment, alcoholic or nutritional-associated cardiomyopathy, infection, cirrhosis decompensation, acute alcoholic hepatitis, and kidney impairment. The type of anaesthetic management does not influence the intra- and postoperative courses. Intermittent clamping of the portal vascular triad is better tolerated than prolonged continuous periods of ischaemia—especially in patients with abnormal liver parenchyma. Intraoperative antibiotic prophylaxis must be administered to prevent translocation of intestinal enterobacteria to the systemic circulation in patients with both healthy and diseased livers. Blood-salvage techniques have limited indications in liver resection. Systematic invasive haemodynamic monitoring is no longer warranted. An arterial cannula should only be considered in procedures of long duration and in selected situations likely to cause anticipated circulatory impairment: total liver vascular occlusion, repeat surgery, combined organ resection, and surgery conducted on tumours >10 cm in size or in connection with the vena cava. In a recent large series of liver resections, 60% of patients did not need a blood transfusion, only 2% of transfused patients received >10 units of blood and cirrhosis was not predictive of increased intraoperative bleeding. Postoperative ascites, which always develops at the expense of circulating fluid, is a frequent occurrence in patients with healthy or diseased livers. Intra- and postoperative fluid limitation does not prevent postoperative ascites. Volume expansion, diuretics and vasopressor therapy should be initiated early to prevent kidney failure.

Background and objective: Doppler echocardiography of diastolic transmitral flow velocity is more sensitive for the detection of myocardial ischaemia in awake patients than echocardiographic analysis of systolic wall motion. However, its diagnostic value in anaesthetized patients is unknown.

Methods: Doppler indices of diastolic transmitral flow velocity previously found to be highly sensitive for detecting ischaemia in awake patients were studied in 72 anaesthetized patients with documented coronary artery disease undergoing dobutamine stress echocardiography. These Doppler indices were compared with standard echocardiographic and electrocardiographic criteria for ischaemia.

Results: Sixty-five patients showed evidence of ischaemia by standard echocardiographic and/or electrocardiographic criteria, and seven patients did not. Regardless of evidence of ischaemia by standard criteria, the Doppler indices changed similarly in both groups. Accordingly, only a minority of anaesthetized patients displayed the changes in Doppler indices of diastolic transmitral flow previously suggested to be sensitive for detecting ischaemia.

Conclusions: The results do not confirm the diagnostic value of Doppler echocardiography of diastolic transmitral flow velocity for detecting ischaemia in anaesthetized patients undergoing dobutamine stress echocardiography during positive-pressure ventilation of the lungs.

Background and objective: Myocardial ischaemia and infarction are major complications immediately after coronary artery bypass grafting. They may be due to incomplete surgical revascularization, perioperative anaesthetic management or vasospasm of arterial grafts, e.g. the internal mammary artery. Infusions of nifedipine or milrinone have been advocated to prevent spasm of the mammary artery. The study compared the incidence of myocardial ischaemia after continuous infusion of either nifedipine (0.2 µg kg−1 min−1) or milrinone (0.375 µg kg−1 min−1) in patients with compromised left ventricular function scheduled for elective coronary artery bypass graft.

Methods: After Institutional Review Board approval, this double-blinded randomized clinical study enrolled 30 adult patients with compromised left ventricular function (ejection fraction <0.4) scheduled for elective coronary artery bypass grafting after written informed consent had been obtained. Ischaemia was detected by Holter electrocardiographic monitoring. The incidence of myocardial cell death was monitored by serial determinations of the creatine kinase-MB (CK-MB) and troponin-I.

Results: New ST elevation ≥0.2 mV or new ST depression ≤0.1 mV occurred in five of 15 patients in the milrinone group (33.3%) and in 13 of 15 patients (86.6%) in the nifedipine group (P < 0.05). There were increases in CK-MB and troponin-I in both groups. Twenty-four hours postoperatively, CK-MB (P = 0.003) and troponin-I (P = 0.001) were significantly higher in the nifedipine group.

Conclusions: Perioperative continuous infusion of milrinone, compared with nifedipine, results in a significantly lower incidence of myocardial ischaemia and myocardial cell damage after elective coronary artery bypass grafting.

Background and objective: A critical factor that delays patient discharge following day-surgery is severe postoperative pain and the requirement for strong analgesics. Laparoscopic sterilization is a day case procedure and is associated with additional postoperative pain compared with diagnostic laparoscopy. This pain, associated with application of Filshie clips, may be ischaemic or spasmodic in aetiology. Papaverine relaxes smooth muscle, and the aim of the study was to investigate if papaverine would be effective in improving postoperative pain if administered directly to the Fallopian tubes. Bupivacaine is used commonly in day-surgery and so we compared the effect of this local anaesthetic with saline placebo.

Methods: Sixty-six ASA I-II females undergoing laparoscopic sterilization were entered into the prospective, randomized, double-blind, placebo-controlled clinical trial. They received intrauterine papaverine (30 mg) or bupivacaine (0.375% 30 mL) or normal saline (30 mL) via the transcervical route before application of Filshie clips.

Results: There were no significant differences in the postoperative period between the three groups in the number of patients needing analgesia in the first 60 min postoperatively, the time to first analgesia, the rescue analgesic or antiemetic consumption, the incidence of postoperative nausea and vomiting, and the sedation and visual analogue pain scores.

Conclusions: From the data presented, we would not recommend routine transcervical administration of papaverine or bupivacaine for pain following laparoscopic sterilization.

Background and objective: The effects of altering the concentration of a local anaesthetic on the development of epidural anaesthesia in pregnant females are unclear. We compared the anaesthetic effects of a constant dose of two different concentrations of epidural lidocaine for Caesarean section.

Methods: After Institutional Review Board approval and informed consent, patients undergoing elective Caesarean section were randomized to receive either lidocaine 1% 30 mL (+epinephrine 5 μg mL−1) or lidocaine 2% 15 mL (+epinephrine 5 μg mL−1) (n = 20 each) for epidural anaesthesia at the L1-L2 interspace. The spread of the sensory block to pinprick and the degree of motor block (modified Bromage scale) were measured at 5, 10, 15, 20 and 30 min after injection.

Results: No significant differences in the progression of analgesia and motor block were observed at any time between 1 and 2% lidocaine. The maximum cephalad spread was observed 30 min after injection; the median was at T4 (range T3–T5) and at T4 (range T3–T6) for lidocaine 1 and 2%, respectively.

Conclusions: The same doses but different volumes of lidocaine 1 and 2% produced comparable anaesthetic effects in pregnant females. The effects of epidural anaesthesia depend primarily on the total dose of the local anaesthetic.

Background and objective: Epidural analgesia with bupivacaine plus either sufentanil or fentanyl is widely used during labour, but it is not clear which opioid is to be preferred. The study compared these opioids at equianalgesic doses in terms of analgesia, onset time and side-effects.

Methods: Ninety females in active labour were entered into the randomized, double-blind trial. A test dose of bupivacaine was given into the epidural space. Parturients in Group S received sufentanil 8 mL as a bolus dose, followed by an infusion at a rate of 5 mL h−1 of a mixture containing sufentanil 1 µg mL−1 and bupivacaine 1 mg mL−1. Patients in Group F received fentanyl 8 mL as a bolus, followed by an infusion at 5 mL h−1 of a solution containing fentanyl 3.5 µg mL−1 and bupivacaine 1 mg mL−1. Additional boluses of 5 mL were of the relevant solution were given if necessary.

Results: In a ratio of 1.0 : 3.5 (sufentanil 1 µg versus fentanyl 3.5 µg), both groups reported the same analgesia with the same onset time. The onset time to obtain 50% of the initial visual analogue score was 10 and 11 min for Groups S and F, respectively. Mean visual analogue scores in Groups S and F respectively declined from 77 and 82 before epidural blockade, to 29 and 27 during the first stage of labour, and to 69 and 59 respectively during the second stage. Overall satisfaction among parturients was high (98 and 96%), particularly during the first stage (98 and 98%), and also to a large degree during the second stage of labour (74 and 79%). Furthermore, only a few extra bolus doses were required (mean 0.9 and 1.2, Groups S and F, respectively). All the females could stand on their own, and almost all (81% Group S; 79% Group F) could walk 20 m without help. There were no serious adverse effects. Moderate side-effects occurred equally often with the possible exception of less nausea and vomiting in the fentanyl group.

Conclusions: Epidural analgesia for ambulatory parturients with bupivacaine plus either sufentanil or fentanyl (ratio 1.0 : 3.5) provides good analgesia with a low frequency of modest side-effects. No clinical differences were found between the opioids.

Background and objective: The aim was to determine if the intravenous administration of sufentanil or clonidine before the induction of anaesthesia could obtund the increase of intraocular pressure associated with rapid-sequence induction.

Methods: Thirty-two ASA I—II patients with no history of eye illness scheduled for elective non-ophthalmic surgery were randomly assigned to receive either sufentanil 0.05 µg kg−1 i.v. (Group A, n = 15) or clonidine 2 µg kg−1 i.v. (Group B, n = 17) prior to induction. General anaesthesia was induced with thiopental (5 mg kg−1) followed by succinylcholine 1 mg kg−1 to facilitate tracheal intubation. The general anaesthetic technique was standardized in both groups. Intraocular pressure was measured using the Schioetz tonometer just before the succinylcholine administration (t0), just before tracheal intubation (t1) and immediately after intubation (t2). Mean arterial pressure and heart rate were recorded at the same time intervals.

Results: Intraocular pressures were similar in both groups at t0, but the sufentanil group had significantly lower values compared with the clonidine group just before (t1) and immediately after tracheal intubation (t2).

Conclusions: Sufentanil is effective in blunting the increase in intraocular pressure caused by rapid-sequence induction with succinylcholine, while clonidine did not seem to have any effect in intraocular pressures just before (t1) and just after (t2) intubation.

Background and objective: The aim was to examine the course of intraocular pressure after relaxation with different doses of cisatracurium.

Methods: The investigation was carried out as a prospective, randomized double-blind study in a crossover design in 30 postoperative patients with stable haemodynamic and respiratory function (ASA I and II). To exclude any disrupting factors, patients remained intubated and continuously sedated. Twenty patients received an intubation dose (2 × ED95) of cisatracurium (0.1 mg kg−1) compared with atracurium (0.5 mg kg−1). In a second series, 10 patients were given an effective dose, ED95 (0.05 mg kg−1), and a repeat dose (0.02 mg kg−1) of cisatracurium. The intraocular pressure was determined before (T0) as well as 1 (T1), 5 (T5), 10 (T10), 15 (T15), 20 (T20) and 45 (T45) min after bolus administration.

Results: Intraocular pressure decreased after an intubation dose of either cisatracurium or atracurium, and reached a minimum after 10 min (6.7 ± 2.2 and 7.9 ± 2.1 mmHg, respectively). There was no significant difference between either muscle relaxant (P = 0.27). When lower doses of cisatracurium (0.05 and 0.02 mg kg−1) were applied, the intraocular pressure also decreased, albeit to a lesser extent and with a delayed onset (8.4 ± 1.9 mmHg after 10 min, 9.9 ± 3.4 mmHg after 15 min). There was no significant difference between dosages (P = 0.44).

Conclusions: Cisatracurium is a useful drug in patients when a decrease of intraocular pressure is wanted and where muscle relaxation is necessary and acceptable.

Background and objective: To determine whether prior exposure of non-steroidal anti-inflammatory drugs increases perioperative blood loss associated with major orthopaedic surgery.

Methods: Fifty patients scheduled for total hip replacement were allocated to two groups (double blind, randomized manner). All patients were pretreated for 2 weeks before surgery: Group 1 with placebo drug, Group 2 with ibuprofen. All patients were injected intrathecally with bupivacaine 20 mg plus morphine 0.1 mg, in a total volume of 4 mL, to provide surgical anaesthesia.

Results: The presence of severe adverse effects caused eight patients in the ibuprofen group and six in the placebo group to terminate their participation in the trial. The perioperative blood loss increased by 45% in the ibuprofen group compared with placebo. The total (±SD) blood loss in the ibuprofen group was 1161 (±472) mL versus 796 (±337) mL in the placebo group.

Conclusions: Pretreatment with ibuprofen before elective total hip surgery increases the perioperative blood loss significantly. Early discontinuation of non-selective non-steroidal anti-inflammatory drugs is advised.