We report a case of accidental intra-arterial injection of propofol in a 30-year-old woman admitted for curettage. The patient reported pain, which was followed by a hyperaemic area of 6 × 7 cm around the injection site. Later a blanching of the distal part of the hand was noticed, lasting for 3 min. When pain appears during propofol administration, an intra-arterial injection must be excluded.

Summary

Background and objective: There are anecdotal reports of dysphoria occurring in patients on the first day after anaesthesia with remifentanil. This study was performed to investigate this allegation and to find a possible relationship to postoperative shivering or to nausea and vomiting.

Methods: Patients undergoing otorhinolaryngeal surgery took part in a prospective, randomized, double-blind study comparing total intravenous anaesthesia with propofol (2 mg kg−1 bolus injection then 100 μg kg−1 min−1) and remifentanil (1 μg kg−1 bolus then 0.1–0.5 μg kg−1 min−1) or alfentanil (30 μg kg−1 bolus then 0.16–0.83 μg kg−1 min−1). The patients were carefully insulated and actively warmed by convective heating and rectal temperature was monitored continuously. Postoperative shivering was graded on a three-point scale, and the cumulative incidence of nausea and vomiting were registered at 24 h after surgery. Pre- and postoperative mood was measured with the von Zerssen mood scale (Befindlichkeits-Skala) and changes tested for significance. High scores reflect discontent and dysphoria.

Results: The data of 98 patients (49 in each group, ASA I–II, age 42 ± 13 yr, anaesthesia time 141 ± 60 min; mean ± SD; intergroup P values >0.1) were evaluated. Core temperature did not change perioperatively (before 36.6 ± 0.2°C; after 36.8 ± 0.3°C, inter- and intragroup P > 0.1). The incidence of nausea was the same in each group; vomiting occurred with equal frequency (6/49 vs. 7/49). Shivering was significantly more frequent after remifentanil (41% vs. 10%, P < 0.001). The patients' mood remained stable after remifentanil but worsened after alfentanil (von Zerssen score from 9.3 ± 2.5 to 13.9 ± 3.6; mean ±95% confidence intervals; P < 0.01).

Discussion: Postoperative shivering was more frequent after remifentanil but was unrelated to intraoperative heat loss. Contrary to preliminary informal observations, there was no evidence that remifentanil caused post-anaesthetic dysphoria on the day one after surgery.

The disposition of propofol in the blood and brain of New Zealand rabbits was studied in three groups of six rabbits. One group received a single anaesthetic dose; a second group received a 1-h infusion; and a third group was studied after the rabbits were judged to have recovered from a 1-h infusion. There was a high concentration of propofol in the red blood cell fraction and in the brain, however, the red blood cell concentration largely exceeded the one found in the brain in all groups of animals. This is consistent with the high fat solubility of diisopropylphenol. The possible effects of propofol sequestered in red blood cells is discussed.

In a multicentre, randomized, double-blind, placebo-controlled dose-ranging study, 1030 patients undergoing outpatient surgery with general anaesthesia received i.v. dolasetron mesylate (12.5, 25, 50, or 100 mg) or placebo. The principal outcome measure was the proportion of patients who were free of emesis or rescue medication for the 24-h period after the study drug was given; the subsidiary outcome measure was survival time without rescue medication. Effects on nausea were quantified using a visual analogue scale. Compared with placebo, a complete response was significantly higher when all four dolasetron doses were combined (49% vs. 58%, P = 0.025). In females, dolasetron, 12.5-mg, dolasetron provided maximum clinical benefit (effectiveness compared with adverse events), with no additional benefit in complete response rates or nausea visual analogue scale scores at higher doses. No significant differences were observed in complete response for any dolasetron dose in males compared with placebo. The majority of adverse events reported were mild or moderate. Dolasetron provided well-tolerated, safe, and effective prophylaxis for post-operative nausea and vomiting with maximum effectiveness observed at a dose of 12.5 mg.

The effects of hydroxyethyl starch on blood coagulation were investigated in 20 patients undergoing surgery to determine whether its use places recipients at risk of haemorrhage or thrombosis. The partial thromboplastin times are significantly prolonged; factor VIII activities and fibrinogen levels are decreased. After infusion of hydroxyethyl starch, no significant differences were detected in platelet count or prothrombin time. A decreased platelet aggregation was also found after the infusion of hydroxyethyl starch. According to our results, hydroxyethyl starch can cause haemorrhagic problems in patients when administered as a colloidal volume-expanding agent.

Anaesthesiologists, for their knowledge, skills and expertise, have been playing a key role in the development of emergency medicine. In many countries, anaesthesiologists are today fully involved in teaching and practicing emergency medicine, and have leading roles in emergency departments. Proper education and effective interdisciplinary medical cooperation is essential for quality assurance in emergency medicine. This paper, produced by a working party of the European Board of Anaesthesiology of the European Union of Medical Specialists (EUMS/UEMS), gives directions for a core curriculum in emergency medicine integrated in the specialty of anaesthesiology.

Background and objective This open, multicentre study compared the efficacy and safety of remifentanil with fentanyl during balanced anaesthesia with 0.8% isoflurane (end-tidal concentration) for major abdominal and gynaecological surgery, and the efficacy and safety of remifentanil for pain management in the immediate postoperative period.

Methods Two-hundred and eighty-six patients were randomized to receive remifentanil 1 μg kg−1 followed by 0.2 μg kg−1 min−1 (n = 98), remifentanil 2 μg kg−1 followed by 0.4 μg kg−1 min−1 (n = 91) or fentanyl 3 μg kg−1 (n = 97) at induction. Thereafter, the study opioids and isoflurane were titrated to effect during the operation.

Results Compared with fentanyl, remifentanil 2 μg kg−1 followed by 0.4 μg kg −1 min−1 reduced the incidence of response to tracheal intubation (30% vs. 13%, P < 0.01), skin incision (33% vs. 4%, P < 0.001) and skin closure (11% vs. 3%, P< 0.05), respectively. Patients receiving remifentanil 1 μg kg−1 followed by 0.2 μg kg −1 min−1 had fewer responses to skin incision than the fentanyl group (12% vs. 33%, P< 0.001), but the incidences of response to tracheal intubation and skin closure were similar. Significantly fewer patients in both remifentanil groups had ≥ 1 responses to surgical stress intraoperatively compared with fentanyl (68% and 48% vs. 87%, P < 0.003). The mean isoflurane concentrations required were less in both remifentanil groups compared with the fentanyl group (0.1%, P = 0.05). In remifentanil-treated patients, continuation of the infusion at 0.1 μg kg−1 min−1 with titration increments of ± 0.025 μg kg−1 min−1 was effective for the management of immediate postoperative pain prior to transfer to morphine analgesia. However, a high proportion of patients experienced at least moderate pain whilst the titration took place.

Conclusions Anaesthesia combining isoflurane with a continuous infusion of remifentanil was significantly more effective than fentanyl at blunting responses to surgical stimuli. Significantly fewer patients responded to tracheal intubation with remifentanil at 0.4 μg kg−1min−1, supporting the use of a higher initial infusion rate before intubation. Both remifentanil and fentanyl were well-tolerated, with reported adverse events typical of μ-opioid agonists.

Treatment of ingrowing toenail is commonly performed under local anaesthesia with a digital ring block. Ring block can be associated with significant pain, caused by needle insertion and deposition of the local anaesthetic agent. EMLA, a topical anaesthetic cream, is widely used to alleviate the pain of venepuncture. The aim of this study was to investigate whether the discomfort of digital block could be reduced by prior application of EMLA. Fifty–five patients who were scheduled for ingrowing toenail under local anaesthesia were randomized into two groups. In Group 1 (n = 30), EMLA was applied around the base of the affected hallux for at least 1 h before ring block. In Group 2 (n = 25), a placebo cream was used. In this double-blind study, patients assessed the pain caused by a standardized ring block using 100-mm visual analogue pain score. The mean visual analogue pain score in Group 1 was 28.1 and 50.1 in Group 2 (P<0.0001). We conclude that EMLA significantly reduces the pain associated with digital ring block.

Background and objective: Patients' perception of limb position during regional anaesthesia is frequently incorrect. The incidence and nature of this phenomenon has not yet been completely described. The aim of this prospective study was to assess phantom sensation in patients undergoing a brachial plexus block.

Methods: Axillary block was performed in 81 patients with the aid of a peripheral nerve stimulator. Immediately after the block, patients were allocated randomly to two groups (Group 1, n = 40; Group 2, n = 41) to have the blocked limb placed either on their thorax or in abduction. Fifteen minutes later, when the block was complete, the position of the limb was changed, without the knowledge of the patient, to a new position of abduction and flexion of the forearm. Patients were questioned about the new limb position. Fifteen minutes later, the limb was then transiently shown to the patient and further placed ‘blindly’ to another position. Patients were once more questioned about this new position.

Results: Correct perception was more frequently observed in both groups following the first interview. Thirty-two and 34 patients gave at least one erroneous response about their limb position when it was initially placed on the thorax or in abduction respectively. Transient visualization of the limb position did not improve the rate of correct response.

Conclusions: Patients' perception of the position of the limb after axillary block in the majority of instances was probably due to persisting sensory inputs from the shoulder joint, which is not involved in this block. This in contrast to supraclavicular or interscalene blocks. A significant number of patients experienced phantom limb sensation. They reported an arm position in fact related to the position of their arm before the axillary block.

Summary

Background and objective: End-stage liver disease is associated with an imbalance in the autonomic nervous system. The purpose of this study was to estimate the effect of liver transplantation on this imbalance. Method: The study involved 10 patients undergoing liver transplantation and 9 patients without liver impairment undergoing liver surgery. The spontaneous baroreflex sensitivity was measured before and 1 month after surgery for the liver surgery group; before and 1, 3, 6, 12 and 18 months after orthotopic liver transplantation. Results: The spontaneous baroreflex slope of patients with end-stage liver disease was decreased before liver transplantation compared to the liver surgery group (3.9 ± 2.5 ms mmHg−1 vs. 9.9 ± 5.0 ms mmHg−1, P = 0.002). The mean slope was significantly increased at 12 and 18 months compared to the pre-transplantation value (3.9 ± 2.5 ms mmHg−1 vs. 8.1 ± 6.6 ms mmHg−1 and 7.4 ± 4.8 ms mmHg−1, respectively; P = 0.042). Nevertheless, further analysis of individual data showed that only four patients exhibited a marked increase in their baroreflex slope 12 months after the liver transplantation whereas it remained decreased in the six others. Conclusions: These results confirm that the baroreflex sensitivity is depressed in end-stage liver disease in line with an autonomic nervous system imbalance. The liver transplantation reverses this disturbance only in some patients.

A recent study in our department demonstrated that depressing the plunger of a 50-mL syringe was reliably and linearly related to the force applied between 20N and 50N. Using a 50-mL syringe we constructed a simple device to help train anaesthetic assistants to apply cricoid pressure correctly. We then tested anaesthetists, operating department practitioners (non-physicians) and nurses in our hospital to see if they could correctly apply forces of 20 and 40 N. All subjects were then trained using this apparatus and once confident were retested immediately afterwards, and again 1 week and 1 month later. The results show a wide variation in the force applied with only 30% of subjects applying appropriate force at 20N, and 40% at 40N. Training leads to a significant improvement in performance (P < 0.005 at 20N and P < 0.001 at 40N) which is maintained for 1 week for both 20N (P < 0.05) and 40N (P < 0.05) but not for 1 month. Therefore training should be practised on a weekly basis. This is an inexpensive and simple device that we believe to be useful in helping anaesthetic assistants to apply effective cricoid pressure.

The pathophysiology of hydrocephalus can be modelled and described in terms of altered biomechanical parameters. Shunting is aimed to correct the patient’s cerebrospinal fluid dynamics, compensating for inadequate cerebrospinal fluid re-absorption or insufficient volume buffering reserve. Computerized infusion studies implement intracranial pressure and arterial pressure signal processing and model analysis to allow the estimation of cerebrospinal dynamics variables such as cerebrospinal fluid outflow resistance, brain compliance and pressure–volume index, estimated sagittal sinus pressure, cerebrospinal fluid formation rate, compensatory reserve and cerebral vasoreactivity.

Infusion studies can assist in the prognostication of normal pressure hydrocephalus and in the diagnosis of idiopathic intracranial hypertension. The technique is also helpful in the assessment of shunt malfunction, including posture-related over-drainage and shunt obstruction.

Ketamine 3–6 mg kg−1 given by mouth to paediatric patients for anaesthetic premedication was evaluated. Forty-three children, ages 2–9 years were randomly allocated to receive either ketamine (3 or 6mg kg−1) or placebo (cola 0.2 mL kg−1). Oral use of ketamine made separation from the families easier, gave an increased level of sedation, made acceptance of mask application easier and improved the emotional state in the recovery phase. These improvements were present with ketamine 3mg kg−1 and 6mg kg−1 in comparison with the placebo. We conclude that 3mg kg−1 ketamine given by mouth to premedicate paediatric patients is as effective as 6mg kg−1 but has a decreased incidence of side effects such as nystagmus and vomiting.