Background and objective: A new posterior approach to the sciatic nerve in the subgluteal region was developed. We describe our clinical experiences on 135 consecutive patients.

Methods: All blocks were performed with a nerve stimulator (stimulation frequency 2 Hz; intensity from 1 reduced to ≤0.5 mA before application). A line was drawn from the greater trochanter to the ischial tuberosity of the femur; then, from the mid-point of this line, a second line was drawn perpendicularly and extended caudally for 4 cm: the end of this line represented the entry point of the needle. Sciatic stimulation was elicited at ≤0.5 mA; then ropivacaine 0.75% 20 mL was injected. An independent observer recorded the time from needle insertion to successful sciatic nerve stimulation (performance time), the depth of appropriate sciatic stimulation and the number of needle redirections, as well as the quality of nerve block, the discomfort during the procedure and patient acceptance.

Results: The performance time was 41 ± 25 s (mean ± SD) and the mean (SD) depth at which the sciatic nerve stimulation was found was 45 ± 10 mm. The median (range) number of needle redirections required to find the proper sciatic stimulation was 2 (1–5). The tibial response was observed in 77 patients (57%), while the common peroneal response was observed in 58 patients (43%). The degree of discomfort reported was very low and only 16 patients (12%) reported severe pain during placement of the block. The onset time (mean ± SD) of sensory and motor block was 7 ± 4 and 17 ± 13 min respectively, and the surgical procedure was completed with only the peripheral nerve block in 127 patients (94%). The same anaesthesia procedure was acceptable by 127 patients (94%) and only eight patients (6%) would prefer a different anaesthesia technique in the future.

Conclusions: The study demonstrated that the sciatic nerve can be easily blocked using this new posterior subgluteal approach, suggesting that it represents a safe and effective alternative to block the sciatic nerve at a proximal level, with the potential for reducing the discomfort experienced by the patient during block placement.

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.

This study was designed to examine the effect of volume loading on haemodynamic responses and regional cardiac function in dogs subjected to two infusion rates of propofol. Instrumentation was established to measure aortic and left ventricular pressures, cardiac output and myocardial segmental lengths. Measurements were taken during two successive infusion rates of propofol: 0.2 (P0.2) and 0.4 (P0.4) mg kg−1 min−1. One group (VL+) (n=6) received volume loading (dextran 40, 10 mL kg−1 h−1), the other group (VL−) (n=6) received only basal perfusion (Ringer solution, 2 mL kg−1.h−1). Regional blood flows were measured by radio-labelled microspheres. P0.4 induced a decrease in cardiac output and in dP/dtmax. End-diastolic length decreased with propofol without any difference between groups. Regional contractility was not modified by propofol or by volume loading. P0.4 decreased endocardial and epicardial blood flow in the VL-group only. Renal, small intestine and large intestine blood flows decreased in both groups with P0.4. P0.2 did not alter regional blood flows significantly. It was concluded that in this model, propofol infusion at 0.4 mg kg−1 min−1 induced splanchnic, renal and myocardial hypoperfusion in animals not submitted to a mild fluid loading. Fluid loading allowed myocardial perfusion to be maintained but could not prevent a marked decrease in splanchnic and renal perfusion.

The aim of the study was the determination of the influence of ventilation modes on the consumption of analgesics and sedatives, duration of intubation and pulmonary gas exchange. Assist/controlled mandatory ventilation (S-CMV, 123 patients), synchronized intermittent mandatory ventilation (S-IMV, 431 patients) and biphasic positive airway pressure ventilation (BIPAP, 42 patients) were compared in a prospective, controlled, open clinical trial over an 18-month period. Five hundred and ninety-six adult patients with normal pulmonary function before surgery and uneventful course following coronary artery bypass graft surgery were studied. Patients ventilated with BIPAP had a significantly shorter mean duration of intubation (10.1h, P < 0.05) than patients treated with S-IMV (14.7 h) and S-CMV (13.2 h). In the S-CMV group, 39.9% of the patients required single or multiple doses of midazolam, but only 13.5% in the S-IMV group and 9.5% in the BIPAP group. The mean total amount of midazolam administered to these patients was significantly higher in the S-CMV group (8.8 mg) than in the S-IMV group (6.6 mg, P < 0.05) and in the BIPAP group (4.3 mg, P < 0.05). The consumption of pethidine and piritramide did not differ between S-CMV and S-IMV, but was significantly lower during BIPAP (P < 0.05). After extubation the patients’ PaCO2 was highest in the S-CMV group. We conclude that ventilatory support with BIPAP reduces the consumption of analgesics and sedatives, and the duration of intubation. The possibilty of unrestricted spontaneous breathing in all phases of the respiratory cycle is considered to be the reason. BIPAP seems to be an alternative to S-CMV and S-IMV in short-term ventilated patients.

Background and objective The endovascular treatment of abdominal aortic aneurysms has raised great interest amongst vascular surgeons. The aim of this study was to com pare the postoperative morbidity and mortality rates of endovascular treatment with those of open surgery, from the anaesthesiologist's standpoint.

Methods From January 1997 to June 2000, 425 consecutive patients with abdominal aortic aneurysms were referred for regular surgery. Thirty-nine patients who needed a visceral or renal artery revasculariza-tion, or a nephrectomy were excluded. The remaining 386 patients were studied in a prospective manner. Aneurysms were evaluated with spiral computerized tomography scanning and calibrated aortography. After informed consent, only those patients with a suitable vascular anatomy underwent endovascular treatment (n = 193). All other patients underwent open surgery and are considered as a control group n= 193). Endovascular treatment was performed by a femoral or an iliac retroperitoneal route. All stent-grafts were made to measure using auto-expandable stainless-steel stents covered with a standard polyester prosthetic graft.

Results Six patients in the endovascular treatment group needed to be converted to the open surgical technique (during the same operation) because of rupture of the iliac bifurcation (1 patient), a large en-doleak (2 patients), or technical problems (3 patients).

Conclusion The amount of bleeding and the need for blood products were significantly lower in the endovascular treatment group. Despite the absence of significant differences regarding cardiac complications and mortality, there was a lesser incidence of pneumonia, acute respiratory and renal failure. Patients in the endovascular treatment group spent less time in the intensive care unit and in the Hospital.

The increasing use of ambulatory surgery requires methods of anaesthesia that allow patients to be discharged soon after the operation is completed. Spinal anaesthesia is usually simple and quick, and the incidence of post-spinal headache has been reduced by using non-cutting small-gauge needles. Limiting the spread of spinal anaesthesia, as long as it still provides analgesia for surgery, should reduce the haemodynamic effects and speed recovery. Restricted spinal anaesthesia, intended to be unilateral using 0.18% hypobaric bupivacaine via a 25G or 27G Whitacre unidirectional needle, was compared with epidural anaesthesia (using a mixture of lignocaine and prilocaine) in 64 matched-pair patients undergoing ambulatory arthroscopy. Motor blockade, assessed for the specific myotomes L2 to S1, was significantly more unilateral in the spinal group. Two patients in the spinal group and nine patients in the epidural group were treated for hypotension (P < 0.05). One patient in the spinal group developed a post-spinal headache. One patient in the epidural group rated the anaesthesia poor.

A 51-year-old man presented with a right upper lobe adenocarcinoma with carinal extension. He underwent a right sleeve pneumonectomy, which involved a carinal resection with anastomosis between the trachea and left main bronchus. This report describes the successful use of jet ventilation, administered via the lumen of the bronchial blocker of a Univent tube. During 15 min of carinal resection, oxygenation of his left lung was maintained with the bronchial blocker bridging the airway discontinuity.

Summary

Background and objective: We tested the hypothesis that disturbances of the visual pathway persist following general anaesthesia, even after normal clinical discharge criteria have been met.

Methods: We performed full-field flash electroretinography in the right eye of 10 unpremedicated ASA I patients who underwent N2O/sevoflurane anaesthesia. Electroretinograms were recorded preoperatively, immediately after discharge from the recovery room and 2 h after discontinuation of sevoflurane. The time at which postanaesthesia discharge score first exceeded 9 was also noted. Data were analysed using paired, one-tailed Student's t-test.

Results: Latency of the b-wave on the photopic electroretinogram was greater at each postoperative time point (30.5 ± 0.9 and 30 ± 1.3 ms), compared to preoperative values (29.2 ± 0.8 ms, P < 0.001 and P = 0.04, respectively). The A–B amplitude of the b-wave was less postoperatively (220.3 ± 52.7 and 210.3 ± 42.7 μV) compared to values before operation (248.1 ± 57.6 μV, P = 0.03 and P = 0.01, respectively). Oscillatory potential latencies were greater at each postoperative time point (21.4 ± 0.5 and 20.8 ± 0.6 ms) compared to before operation (20.4 ± 0.4 ms, P < 0.001 and P = 0.03, respectively). Oscillatory potential amplitudes were less at the first postoperative time point (17.5 ± 6.1 μV), compared to preoperative values (22 ± 6.4 μV, P = 0.04).

Conclusions: Postoperative electroretinogram abnormalities are consistently present in patients who have undergone N2O/sevoflurane anaesthesia. These abnormalities persist beyond the time at which standard clinical discharge criteria have been met.

Health care systems throughout the world are faced with continuously rising health care expenditure. In Germany, a fee per capita system will be introduced by 2003 to keep the budgets for hospital care within limits. As a result, numbers of hospital beds and hospitals will be cut in the coming years. On the other hand, more and more patients and health care providers are asking if they are really receiving an adequate value for their money in the treatment they receive. All this will have a strong impact on the anaesthesiologist's work and her/his perception of the different facets of quality.

Quality has various aspects for the anaesthesiologist. The patient as a customer should not incur any detrimental effects after a surgical procedure, and is accompanied by the anaesthesiologist throughout the perioperative setting. The surgeon needs optimal conditions to perform a procedure. The hospital must balance equally costs and income; this requires optimal operating room utilization. Finally, health insurance companies and the government are responsible for covering the cost of treatment according to the quality of the care delivered.

Quality assessment concerning structure, process and outcome has to take these demands into account. Continuous quality improvement in the spirit of Deming's ‘plan-do-check-act cycle’ has to be part of anaesthesiologist's everyday routine. In future, the traditional barriers between the specialities treating a patient will be disrupted when reimbursement for treatment is made according to quality and efficacy of treatment.

In this case report, the anaesthetic management for a removal of phaeochromocytoma undertaken immediately following Caesarean section is described. A 32-year-old female patient was given epidural anaesthesia for Caesarean section, and thereafter, general anaesthesia for a resection of phaeochromocytoma. During surgery, phentolamine, nitroglycerine and prostaglandin E1 were electively administered to decrease blood pressure and heart rate. A live infant was delivered and the supra-adrenal tumour was excised successfully. The patient's post-operative recovery was uneventful.

Sixty patients were randomly assigned to two equal groups. Group I received epidural morphine 1 mg after surgery and used a patient-controlled analgesia device programmed to deliver morphine 0.2 mg h−1, 0.2 mg per bolus. Group II received an epidural loading dose of morphine 1 mg plus ketamine 5 mg and used a patient-controlled analgesia device programmed to deliver morphine 0.2 mg+ketamine 0.5 mg h−1, morphine 0.2 mg+ketamine 0.5 mg per bolus with a lockout time of 10 min. The mean morphine consumption was 8.6±0.7 mg for group I and 6.2±0.2 mg for group II. Although group II utilized significantly less morphine (P<0.05), pain relief was significantly better in group II than in group I (P<0.05) in the first 3 h. Vomiting occurred more frequently in group I (26%) than in group II (13%). The frequency and severity of pruritus and level of sedation were similar in the two groups. These findings suggest that patient-controlled epidural analgesia with morphine plus ketamine may provide effective analgesia with a lesser dose of morphine and fewer subsequent side effects, compared with patient-controlled epidural analgesia with morphine alone after lower abdominal surgery.

Background and objective: The study aimed to evaluate and improve airway management in the prehospital setting, i.e. physicians working on board ambulances. A quality control programme focusing on anaesthesia was instituted to improve the time taken to perform endotracheal intubation.

Methods: All consecutive patients requiring tracheal intubation were prospectively analysed before (first period) and after the training programme focusing on anaesthetic protocols for tracheal intubation (second period). The number of attempts at laryngoscopy, the time taken to achieve tracheal intubation, the difficulties encountered and the related complications of the anaesthetic technique were recorded. At the end of the first period, the results were reported to the whole staff of the unit and the anaesthesia protocols were then modified by introducing succinylcholine into the induction sequence, as part of a training programme.

Results: Two-hundred-and-eighty patients were evaluated (97 in the first period, 183 in the second). All patients were successfully intubated in both periods. The percentage of difficult intubations (as assessed by the physician) was lower in the second period (20 versus 35%, respectively; P < 0.01). The success rate at the first attempt was significantly higher (74% [68–80] 95% CI versus 55% [45–65] 95% CI, P < 0.01) and the duration of intubation was significantly shorter in the second period than in the first (1.4 ± 3.2 vs. 4.1 ± 6.7 min, respectively; P < 0.001). The incidence of complications (hypoxaemia, laryngospasm, bronchospasm) was lower in the second period (15 versus 31%, P < 0.01).

Conclusions: The time to perform tracheal intubation can be improved by the introduction of succinylcholine into the prehospital anaesthetic protocol. Rapid sequence induction should be taught as a way of improving tracheal intubation in the prehospital setting.

Summary

Background and objective: This study was performed to determine the individual exposure of paediatric operating theatre personnel to sevoflurane and to evaluate the impact of inhalation induction and various airway approaches on exposure to airborne sevoflurane.

Methods: Mean individual environmental (workplace air) exposure to sevoflurane and a biomarker of exposure (urinary sevoflurane) were monitored in 36 subjects (10 anaesthetists, 10 surgeons, 12 nurses and 4 auxiliary personnel) working in two paediatric operating rooms.

Results: Environmental and urinary values were significantly greater in anaesthetists compared with other groups, with median values of 0.65 ppm (interquartile range 1.36; 95th percentile 4.36) for breathing zone sevoflurane and 2.1 μg L−1 urine (interquartile range 2.6; 95th percentile 7.6) for urinary sevoflurane. Anaesthetists exceeded the 2 ppm maximum allowed environmental concentration recommended by the National Institute for Occupational Safety and Health in 4 of 22 cases (18.1%). A positive correlation was found between the number of patients undergoing inhalational induction each day and mean values of breathing zone and urinary sevoflurane. An increase in the number of daily laryngeal mask insertions, or the use of rigid bronchoscopy, are statistically related to higher environmental and urinary values (P < 0.01 and <0.00001 for breathing zone sevoflurane, P < 0.05 and <0.01 for urinary sevoflurane, respectively).

Conclusions: Anaesthesia with sevoflurane can pose a hazard of chronic exposure with anaesthetists having the highest risk. Endotracheal intubation offers considerable protection against exposure. Routine anaesthesia using a standard facemask, a laryngeal mask or rigid bronchoscopy are risk factors for increased anaesthetic exposure.

Summary

Background and objective: An alteration in production of both interleukin-10 (IL-10) and nitric oxide (NO) has been found following surgical/anaesthesia trauma. It is also suggested that IL-10 could be an important factor in regulating NO metabolism during the postoperative period. Furthermore, NO seems to play a crucial role in the anaesthetic state. The purpose of this study was to investigate plasma levels of IL-10 and NO following surgery, any possible correlation between these two variables and whether anaesthesia technique could influence NO and IL-10 circulating concentrations.

Methods: Thirty-two patients scheduled to undergo elective major surgery were enrolled in the study and allocated into two groups to receive two different techniques of anaesthesia, total intravenous (i.v.) anaesthesia (Group I) and inhalational anaesthesia (Group II). Blood samples were drawn before (t0), at the end (t1) of operation and after 24 h (t2). Plasma IL-10 and NO levels were measured by using an enzyme-linked-immunosorbent assay (ELISA) and a total NO assay kit, respectively.

Results: In both patient groups there was a significant decrease of plasma NO levels at the end of surgery (30.35 ± 2.70 mmol L−1 at t0 to 13.76 ± 1.51 mmol L−1 at t1 in Group I, P < 0.0001; 28.23 ± 2.50 mmol L−1 at t0 to 11.38 ± 0.95 mmol L−1 at t1 in Group II, P < 0.0001). This reduction remained at 24 h postoperatively (14.33 ± 1.52 mmol L−1 in Group I, P < 0.0001; 12.52 ± 1.11 mmol L−1 in Group II, P < 0.0001, both vs. t0). There was an increase in IL-10 concentrations (26.35 ± 3.42 pg mL−1 and 75.39 ± 8.33 pg mL−1 at t1 and t2, respectively, vs. 4.93 ± 0.31 pg mL−1 at t0, P = 0.03 and P < 0.0001, respectively, in Group I; 26.18 ± 3.22 pg mL−1 and 69.91 ± 7.33 pg mL−1 at t1 and t2, respectively, vs. 5.50 ± 0.33 pg mL−1 at t0, P = 0.02 and P < 0.0001, respectively, in Group II). No relationship was found between circulating IL-10 and NO.

Conclusions: During the postoperative period, IL-10 overproduction does not correlate with the decrease in systemic NO concentration.