Post-operative nausea and vomiting is distressing for patients and can cause dissatisfaction and impaired well-being in the post-operative period. This study examined the question whether the reduced incidence of post-operative nausea and vomiting inevitably translates into improved clinical status and well-being. In this context high doses of droperidol were investigated. On the one hand, droperidol is known to be a powerful anti-emetic, but on the other hand there is concern about psychological effects, both in the pre- and the post-operative period. In this prospective randomized double-blinded study, droperidol (5–7.5 mg) was compared with midazolam (5–7.5 mg) used to supplement fentanyl-N2</O based anaesthesia, with respect to post-operative mood and well-being using a psychological questionnaire (Bf-S-test). Furthermore, the incidence of post-operative nausea and vomiting was recorded. Out of 160 patients undergoing thyroidectomy and laparoscopic cholecystectomy, data from 150 patients were analysed. The administration of droperidol significantly lowered the incidence of post-operative nausea and vomiting from 77.8% to 55.1% compared with midazolam (P=0.0059; χ2-test). Although post-operative nausea and vomiting is an independent risk factor for post-operative discomfort and bad mood, patients receiving droperidol showed impaired well-being 6 h after surgery. Well-being scores returned to pre-operative base-line values and did not differ between the two groups 24 and 48 h post-operatively. The reduced incidence of post-operative nausea and vomiting achieved with high dose droperidol does not equate with increased post-operative well-being. It is an important point at issue to decide whether smaller doses of droperidol that are commonly used for anti-emetic therapy are free of these side effects.

Summary

Background and objective: Patients have the right to be informed about the expected benefits and risks of medical and surgical procedures. Ideally this information should be scientifically based and presented to the patient in time. In morbidly obese patient undergoing general anaesthesia, postoperative pulmonary complications are an important cause of postoperative morbidity and mortality. A 46-yr-old female with a body mass index of 89.8 kg m−2 was scheduled to undergo radical abdominal surgery for cervix carcinoma. In order to inform her accurately on the risk of developing postoperative pulmonary complications, we undertook to answer the following question: What is the risk to develop postoperative pulmonary complications in a morbidly obese patient about to undergo abdominal surgery under general anaesthesia? Methods: A Medline search was conducted from 1966 to 2004 with respect to postoperative pulmonary complications in abdominal surgery of morbidly obese patients. Altogether, 213 articles were found, of which seven were selected. Additionally, seven cross-references and or related articles were used. Results: For obese patients who undergo abdominal surgery under general anaesthesia, the likelihood to develop atelectasis is 10.4 ± 4.8% (P < 0.001) with a correlation coefficient of 0.28–0.34 (P < 0.05). The likelihood to develop atelectasis and pneumonia taken together is 29.3% with an adjusted odds ratio of 2.82 (95% confidence interval 1.66–4.78; P = 0.0001). Conclusion: Considering the positive correlation coefficient and the high body mass index of this patient she has a risk of at least 29.3% to develop pneumonia and/or atelectasis, which should affect the anaesthetic strategy in this patient.

Animal and human studies suggest that hypertonic saline is a potential therapeutic agent to assist with the medical treatment of patients with traumatic brain injury. It may have a place as osmotherapy to decrease brain size, predominately of uninjured brain and has several potential advantages over mannitol. Hypertonic saline has clinically desirable physiological effects on cerebral blood flow, intracranial pressure and inflammatory responses in models of neurotrauma. Animal studies support its use, but definitive human trials using mortality end-points in brain trauma are lacking. Hypertonic saline may be considered a therapeutic adjunct to the medical management of traumatic brain injury, awaiting definitive evidence to support routine use.

This study was undertaken to determine whether epidural analgesia has any benefit for post-operative pain relief in patients undergoing laparoscopic cholecystectomy. Patients were randomly assigned to receive post-operative epidural analgesia with a morphine–bupivacaine combination (Group A, n=22) or placebo (saline) (Group B, n=22). The same standard general anaesthetic technique, which consists of nitrous oxide and isoflurane in oxygen was used. Analgesia was assessed using visual analogue pain scores (0–10 cm). The evaluation was carried out 24 and 48 h post-operatively. At 24 h after anaesthesia, pain scores in Group A (2.3±1.2) were lower than those in Group B (4.4±1.5) (P<0.05). However, at 48 h post-operatively, no difference in scores was observed between the two groups. In conclusion, epidural analgesia with a morphine–bupivacaine combination improves pain relief during the first 24 h following laparoscopic cholecystectomy.

Summary

Background and objective: This study was designed to determine if subhypnotic propofol reduces postoperative behavioural disturbances in children undergoing sevoflurane induction compared with intravenous propofol induction for elective adenoidectomy and tonsillectomy. Methods: Following Ethics Committee approval and parental informed consent, ASA I–II, 120 children (2–10 yr) were recruited. Parents were not allowed to accompany their child. Unpremedicated children were randomly allocated to groups receiving inhalation induction with sevoflurane, 2–2.5 mg kg−1 intravenous propofol induction or inhalation induction with sevoflurane followed by subhypnotic dose of propofol (1 mg kg−1). Anaesthesia was maintained with 2–4% sevoflurane, O2 and N2O. Anxiety on arrival to operating theatre, at anaesthesia induction and 30 min after emergence was assessed. Parents completed a state–trait anxiety inventory test preoperatively and a post hospitalization behaviour questionnaire a week later to assess children's postoperative behavioural disturbances. Kruskal–Wallis test, Wilcoxon signed rank sum test, Bonferroni's test, Paired t-test, t-test, Pearson and Spearman's rank correlation test, χ2-test were used for statistical analysis. Results: The anxiety level at induction was high in all groups (P < 0.05). There was no difference between groups in respect to anxiety at other measurement times. A relation between preoperative anxiety level and postoperative behavioural disturbances was determined (P < 0.05). Some behavioural disturbances as nightmare/night fear and desire of sleeping with parents were rarely seen in intravenous propofol induction group (P < 0.05). Conclusion: Addition of subhypnotic dose of propofol to sevoflurane induction did not reduce the incidence of postoperative behavioural disturbances.

Summary

As atelectasis occurs in most patients during general anaesthesia and may be one of the major causes for the development of hypoxaemia and nosocomial pneumonia, its prevention may be considered as an important objective in perioperative management. The major causative mechanisms are the loss of respiratory muscle tone, compression and gas absorption. Vital capacity manoeuvres have been proposed as a means to eliminate atelectasis in the vast majority of patients and restore normal pulmonary gas exchange during general anaesthesia. In this review we describe the pathogenesis of atelectasis in the perioperative period and discuss in the light of recent published investigations the suitability of the vital capacity manoeuvre as a tool during general anaesthesia. Reviewing the current literature, a vital capacity manoeuvre during general anaesthesia may only be useful under specific circumstances when mechanical ventilation with a high inspiratory fraction of oxygen is required or during cardiac surgery at the end of cardiopulmonary bypass to reduce the amount of atelectasis and to maintain adequate gas exchange.

Summary

Background and objective: Clonidine has cardiac and systemic effects that can modify the potentially lethal cardiovascular effects of local anaesthetics. We evaluated the effects of clonidine pre-treatment on cardiotoxicity induced by an infusion of bupivacaine or ropivacaine and the success rate of resuscitation in anaesthetized rats.

Methods: Thirty-two Sprague–Dawley rats (250–300 g) were anaesthetized with thiopental and ketamine. Lung ventilation was maintained mechanically, and the electrocardiograph and invasive blood pressure were recorded continuously. Two separate groups of rats were treated with intravenous clonidine 5 μg kg−1 (n = 16) or saline (n = 16) in a randomized fashion. Fifteen minutes later, each group was randomly subdivided into two equal groups and an infusion of bupivacaine or ropivacaine, 3 mg kg−1 min−1, was given until cardiac arrest (asystole) occurred. The times when the cardiotoxic events (25%, 50% and 75% reduction of arterial pressure and heart rate, first dysrhythmia and asystole, respectively), induced by the local anaesthetic, occurred and the resuscitation outcome scores were recorded.

Results: Clonidine reduced heart rate and arterial pressure (P < 0.01). Clonidine did not alter cardiotoxicity or the success rate of resuscitation in bupivacaine-treated rats. In the ropivacaine group, clonidine increased the 25%, 50% and 75% reduction times of arterial pressure and the 50% and 75% reduction times of heart rate, times to first dysrhythmia and asystole (P < 0.05). Clonidine also increased the success rate of resuscitation in ropivacaine-treated rats (P < 0.05).

Conclusions: Although pre-treatment with clonidine protects the effects of ropivacaine cardiotoxicity and increases the success rate of resuscitation, it does not affect bupivacaine toxicity.

Sixteen patients suffering from rheumatoid or osteoarthritis of the shoulder joint were studied. All patients complained of pain and limitation of active movement of the shoulder joint. Combined neural blockade of the suprascapular nerve (SSNB) and articular branches of the circumflex nerve (ACNB) was carried out using 4 mL of 1% prilocaine and 4 mL of 6% aqueous phenol. Following this procedure, the mean value for pain intensity decreased by 69% (VASP 2.7) and for abduction, adduction and flexion increased by 36–67% over a mean time of 13 weeks. Functional external and internal rotation of the shoulder joint also increased after neural blockade. These findings were significant (P<0.05). Further clinical evaluation of combined SSNB and ACNB in relation to previously reported methods of neural blockade of the shoulder joint is warranted using a randomized, controlled, comparative study. Conventional power calculations (80% power, 5% test) indicate that 17 patients per group would be necessary to detect one standard deviation (about 2 VASP) or 64 per group to detect a change of 0.5 standard deviations.

The aim of this study was to evaluate whether the addition of clonidine, or sufentanil, or both, to a bupivacaine solution for a caudal block prolonged the period of analgesia after operation in children. Sixty ASA class I or II boys, aged between 8 months and 13 years, admitted for hypospadias repair were enrolled into a prospective randomised study. After induction of general anaesthesia and endotracheal intubation the children were allocated into four groups. Group I received 0.5 mL kg−1 bupivacaine 0.25% caudally, in addition group II received 1 mg kg−1 clonidine, group III 0.5 mg kg−1 sufentanil and group IV 0.5 mg kg−1 clonidine and 0.25 mg kg−1 sufentanil. The concentrations of clonidine and sufentanil in group IV were halved to reduce possible side-effects with higher dosages. Analgesia and side-effects were assessed 2, 4, 6, 8 and 12 h after operation. No significant differences were found among the four groups for the pain scores at 2, 4, 6, 8 and 12 h. All groups had a similar frequency of vomiting and a comparable appetite and quality of night rest during the first 24 h following the operation. There was no signficant difference in the requirement for additional doses of analgesics. The addition of sufentanil, or clonidine, or both, to bupivacaine for caudal administration provides no additional clinical benefit over bupivacaine alone.

Summary

Background and objectives: The potential for increased drug administration errors during the transition to the International Colour Coding syringe labelling system has been highlighted. The purpose of this study was to assess the potential effects before their introduction into our department. Methods: Thirty-one anaesthetists, 19 with no previous practical experience of the new labelling system (Group 1), and 12 with previous experience (Group 2), volunteered to induce general anaesthesia for a standardized simulated patient in a designated theatre. They were presented with a scenario designed to suggest the need for a rapid sequence induction and provided with drug syringes labelled with the International Colour Coding system. All drug administrations were recorded. Active error was defined as the injection of the wrong drug. Latent error was defined as the selection of a syringe in error but stopping short of administering the drug. Results: In Group 1 a total of 107 drug injections were recorded of which 1 (0.9%) was an active error and 16 (15%) involved latent errors. Eleven anaesthetists (58%) performed at least one latent error. Group 2 had an error rate of 3%, a 6.9 (1.3–26.7) fold reduction in the rate of error (P = 0.023). Conclusions: Although only one drug was given in active error, latent errors occurred in 15% of drug administrations. The only factor conferring protection against error was prior experience of the new labelling system. The period of transition to the International Colour Coding syringe labelling system represents a time of increased risk of drug administration error.