Summary

Background and objective: The efficiency of bilateral paravertebral blockade combined with general anaesthesia (active) vs. general anaesthesia alone (control) in reducing postoperative pain following laparoscopic cholecystectomy was evaluated using a prospective randomized study design.

Methods: Patients were randomly assigned to either group. Nerve-stimulator guided paravertebral blockade at the T5–6 level was performed with a local anaesthetic mixture (0.30 mL kg−1). Twenty millilitres of the mixture contained lidocaine 2% 6 mL; lidocaine 2% 6 mL with epinephrine 1/200 000; bupivacaine 0.5% 5 mL; fentanyl 1 mL (50 μg mL−1) and clonidine 2 mL (150 μg mL−1). Postoperative pain and consumption of opioids were assessed during the first 72 h.

Results: Two-times 30 patients were analysed. Patient characteristics data, and pre- and peroperative variables were similar in both groups. Mean pain scores visual analogue scale were significantly less with active compared with control (P < 0.05) at 6 h (1.56 ± 1.58 vs. 4.78 ± 1.67), at 12 h (1.52 ± 1.58 vs. 3.81 ± 1.63), at 24 h (1.16 ± 1.34 vs. 2.71 ± 1.50), at 36 h (0.68 ± 1.02 vs. 2.29 ± 1.41), at 48 h (0.60 ± 1.04 vs. 1.61 ± 1.33) and at 72 h (0.40 ± 0.86 vs. 1.19 ± 1.16). The number of patients consuming supplemental analgesics was significantly less (P < 0.05) with active compared with control, at 6 h (6 vs. 29), at 12 h (2 vs. 26), at 24 h (1 vs. 23) and at 36 h (2 vs. 15). More patients were free from nausea (P < 0.05) with active compared with control at 6 h (23 vs. 9) and at 12 h (29 vs. 19).

Conclusion: When used as a complement to general anaesthesia, bilateral nerve-stimulator guided paravertebral blockade with lidocaine, bupivacaine, fentanyl and clonidine may improve postoperative pain relief.

To evaluate the usefulness of the volumetric fluid balance for indicating and quantifying fluid absorption during transurethral resection of the prostate, 62 patients showing fluid absorption on ethanol monitoring (control method) were selected from a series of 410 operations. The volumetric fluid balance, which was measured as the difference between the input and output of irrigating fluid with and without a correction for the blood loss, proved to be an unreliable clinical tool for measuring the absorption. It indicated that fluid absorption occurred only in 40 or 18 of the 62 patients, depending on whether a correction for blood loss was made or not, the volume being only 59% and 71% (median), respectively, of that obtained by the control method. The absorption averaged 1 L in the patients in whom the volumetric measurements did not indicate absorption. The incidence of symptoms of the ‘transurethral resection syndrome’ increased with the absorbed fluid volume only when measured by the control method.

We studied the haemodynamic changes induced by pneumoperitoneum (PP) in elderly patients with increased cardiac risk (ASA class III; n = 10; age 72.3 ± 8.8 years, mean±SD, P < 0.05; group 2) and compared the results with patients at normal risk (ASA class I, II; n = 12; age 55.6 ± 11.8 years; group 1). Thermodilution measurements were performed after induction of general anaesthesia (T1), after onset of PP (T2, intraabdominal pressure 14 mmHg) and after additional 15° head-up tilt (T3). In both groups PP, as compared with T1, induced a significant increase in mean arterial pressure (MAP, mmHg, group 1:77 ± 14 to 96 ± 18, P < 0.05/group 2:75 ± 10 to 102 ± 18, P < 0.01), mean pulmonary artery pressure (MPAP, mmHg: 15 ± 5 to 22 ± 4, P < 0.01/18 ± 3 to 25 ± 5, P < 0.01), central venous pressure (CVP, mmHg: 7 ± 2 to 15 ± 3, P < 0.01/7 ± 2 to 12 ± 2, P < 0.01), pulmonary capillary wedge pressure (PCWP, mmHg: 9 ± 4 to 16.3, P < 0.01/8 ± 2 to 15 ± 6, P < 0.01) and in systemic vascular resistance (SVR, dynes s cm−5: 1415 ± 375 to 1873 ± 412, P < 0.01/1502 ± 360 to 2067 ± 647, P < 0.01). Cardiac index (CI, L min−1 m−2: 2.3 ± 0.3 to 1.9 ± 0.3, P < 0.05/2.2 ± 0.4 to 2.2 ± 0.5 P = 0.76) and oxygen delivery index (DO2I, mL min−1 m−2: 388 ± 54 to 324 ± 61, P < 0.05/358 ± 69 to 353 ± 82, P = 0.77) decreased in group 1 but not in group 2. Heart rate, stroke index, pulmonary vascular resistance, arteriovenous oxygen content difference and oxygen consumption index were unchanged. After head-up tilt MAP (mmHg, 92 ± 15, P < 0.05/101 ± 17, P < 0.01), MPAP (mmHg, 20 ± 3, P < 0.01/22 ± 4, P < 0.05), CVP (mmHg, 12 ± 2, P < 0.01/10 ± 2, P& lt; 0.01) and PCWP (mmHg, 12 ± 3, P < 0.05/12 ± 5, P < 0.05) remained elevated compared with T1 in both groups, SVR (dynes s cm−5, 1575 ± 372, P = 0.13/1793 ± 528, P < 0.01) in group 2 only. No complications occurred. The results indicate that PP is associated with significant but relatively benign haemodynamic changes. Anaesthesia for laparoscopic cholecystectomy may be performed safely also in elderly ASA class III patients with increased cardiac risk. An adequate haemoto dynamic monitoring is recommended.

We present a case of hypoxic brain damage that occurred after intramuscular injection of diclofenac due to a severe anaphylactic reaction. A 38-year-old nurse treated herself for acute lower back pain with 100 mg diclofenac intramuscularly. Five minutes later, she collapsed and developed coma and respiratory arrest. After cardiopulmonary resuscitation she was transferred to hospital. On admission she was comatose and received controlled ventilation of the lungs. Magnetic resonance imaging and computerized tomography showed signs of hypoxic brain injury and the patient died from central cardiopulmonary failure 7 days later. Intramuscular treatment with non-steroidal anti-inflammatory drugs such as diclofenac has rare but potentially severe side-effects. Therefore, intramuscular injections are inappropriate and should be replaced with oral or rectal treatment, which has similar absorption profiles.

Summary

Background and objective: We investigated whether a high bolus dose of cisatracurium (8× ED95) given at induction can provide muscle relaxation for the major part of a cardiac procedure with hypothermic cardiopulmonary bypass, avoid important postoperative residual curarization and cause no waste of product.

Methods: Twenty patients were randomly assigned either to Group 1 (n = 10) or Group 2 (n = 10). Those in Group 1 were given cisatracurium in a high bolus dose (0.4 mg kg−1). Those in Group 2 received cisatracurium 0.1mg kg−1 at induction followed after 30 min by a continuous infusion of cisatracurium. As an escape medication in case of patient movement, a bolus dose of cisatracurium 0.03 mg kg−1 was given.

Results: In Group 1 (large cisatracurium bolus dose), the clinical duration of effect (until T1/T0 = 25%) was 110 min. Six of 10 patients in Group 1 required additional boluses of cisatracurium intraoperatively. Four of these six had received an additional bolus near the end of surgery and had a train-of-four (TOF) ratio = 0 at the end. The other four patients in Group 1 had a final TOF ratio >0.9. In Group 2 (continuous cisatracurium infusion), only two patients had a TOF ratio >0.9 at the end of surgery, no patient moved and none received additional boluses. The total amount of cisatracurium used in the bolus and infusion Groups was 34.5 ± 7.8 and 21.3 ± 5.7 mg, respectively (P = 0.0004).

Conclusions: For continued neuromuscular block during hypothermic cardiac surgery, a high bolus dose of cisatracurium appears to be safe, although it is not an alternative to a continuous infusion, as its neuromuscular blockade does not cover the intraoperative period and a high incidence of movements occurs. In the patients who received a high bolus dose of cisatracurium, postoperative residual curarization appeared after additional boluses had been given. The consumption of cisatracurium by high bolus was significantly greater than with continuous infusion.

Summary

Background and objective: Staff attitude plays a pivotal role in quality management. The objective of the present study was to further define how interdisciplinary emergency hospital staff experience their daily work and the extent to which the professional speciality and training of an individual influences his/her assessment of multiple-trauma team performance. Methods: The clinical staff involved in multiple-trauma emergency management of a university hospital was asked to answer a confidential questionnaire. Factorial analysis was used to identify 8 major dimensions from a total of 53 items. Results: The questionnaire was returned by 128 team members. All professional groups were most dissatisfied with the dimensions ‘education and training’, ‘work sequence between specialities’ and ‘communication between specialities’. Assessment of the quality of in-hospital emergency-trauma management differed significantly between professional specialities (ANOVA, F = 5.2; P = 0.028); surgeons gave the highest ratings for all but one dimension. Having taken an Advanced Trauma Life Support (ATLS®) course influenced significantly the total rating of multiple-trauma treatments of anaesthetists and surgeons (F = 5.5; P = 0.024). Conclusions: The perceptions of interdisciplinary trauma team members without the completion of an ATLS® training course were that they did not communicate enough with each other and that there were differences between their expectations and reality. The differences and the communication deficits were overcome in team members who had passed an ATLS® course.

Summary

Background and objective: Outcome prediction and evaluation of intensive care unit (ICU) performance using severity of illness scoring is a tool for the estimation of effectiveness and quality of intensive care. We used the simplified acute physiology score (SAPS) II system to evaluate ICU performance.

Methods: The present study is a prospective observational study in an ICU at Vilnius University Emergency Hospital, Lithuania. The observed death rate was compared with the predicted death rate calculated using SAPS II system. The ability of the SAPS II prognostic system to predict the probability of hospital mortality was assessed with discrimination and calibration measures.

Results: Two-thousand-and-sixty-seven patients consecutively admitted to the ICU were studied. The median SAPS II score on the first ICU day was 29. The SAPS II system showed a good ability to separate those patients predicted to live from those predicted to die (an area under the receiver operating characteristic curve was 0.883). The calibration curve demonstrated under-prediction of the actual death rate (Hosmer–Lemeshow goodness-of-fit test, χ2 = 56.98; df = 8; P < 0.001). The observed mortality was higher than predicted by the SAPS II equation (observed to predicted ratio is 1.28).

Conclusions: The SAPS II system is a useful tool for the assessment of ICU performance. This system demonstrated a good ability of discrimination, but an under-prediction of the actual mortality rate, in Lithuanian ICUs.

Background and objective The recently developed transcerebral double-indicator dilution technique has proven to be a feasible monitoring alternative to measure global cerebral blood flow at the bedside. However, the short-term repeatability of transcerebral double-indicator dilution measurements has not yet been investigated. The present study was designed to investigate the accuracy in terms of reliability for repeated transcerebral double-indicator dilution measurements to assess global cerebral blood flow during a definite carbon dioxide challenge in a clinical trial.

Methods The investigation was performed in 10 patients scheduled for elective coronary artery bypass grafting. After induction of anaesthesia, repeated cerebral blood flow measurements using transcerebral double-indicator dilution were performed during target normocapnia, hypocapnia and hypercapnia. For transcerebral double-indicator dilution measurements, a bolus injection of ice-cold indocyanine green was administered into a central vein. The resulting thermal dye dilution curves were recorded simultaneously in the aorta and the jugular bulb using combined fibreoptic thermistor catheters. Cerebral blood flow was calculated from the mean transit times of the indicators through the brain. Additionally, transcranial Doppler sonography was simultaneously performed to measure transient changes in the cerebral blood flow velocity.

Results Transcerebral double-indicator dilution measurements revealed a reasonable coefficient of repeatability with 9.1, 9.7 and 20.2 mL min−1100 g−1 during normo-, hypo- and hypercapnic conditions, respectively. However, a total of 20% of the administered measurements had to be rejected for methodological reasons.

Conclusions Repeated measurements with the transcerebral double-indicator dilution method show a reasonable repeatability. With consideration to the limitations of the transcerebral double-indicator dilution technique, this new method proves to be a reliable monitoring tool to measure global cerebral blood flow at the bedside.

Summary

Background and objectives: This study was designed to investigate whether single epidural droperidol or continuous epidural droperidol inhibit pruritus and postoperative nausea and vomiting induced by postoperative continuous epidural fentanyl administration, and to identify the optimal method of administering epidural droperidol. Methods: 120 ASA I–II patients undergoing subtotal gastrectomy with general anaesthesia combined with epidural anaesthesia were randomly allocated into three groups: control (no droperidol), single injection (droperidol 2.5 mg) and continuous group (droperidol 2.5 mg 2 day−1). Postoperatively the frequency and severity of pruritus and postoperative nausea and vomiting in all groups were compared during 48 h. Results: The frequency and severity of pruritus was significantly lower in both single injection and continuous groups than control group after epidural fentanyl administration (P < 0.05). The frequency and severity of postoperative nausea and vomiting was significantly lower in single injection group than control group after epidural fentanyl administration (P < 0.05). Conclusion: Epidural continuous droperidol is effective for reducing pruritus, and single epidural droperidol injection is effective for reducing pruritus and postoperative nausea and vomiting induced by postoperative continuous epidural fentanyl analgesia.

This study compared the effect of two anaesthetic techniques on the catecholamine levels in children undergoing ilioinguinal herniorrhaphy. Forty male paediatric patients ASA class I were allocated randomly to one of two groups: the control group (n=20) received general anaesthesia including intravenous fentanyl; and the caudal group (n=20) received caudal anaesthesia with bupivacaine 0.25% 1mL kg−1; combined with general anaesthesia but without opioids. Plasma adrenaline and noradrenaline concentrations were measured at induction, at the end of surgery and in the post-anaesthesia care unit (PACU). In the caudal group, there were significant decreases in the adrenaline and noradrenaline concentrations at the end of surgery and in the PACU compared with baseline concentrations. In the control group, there was a significant increase in PACU concentrations of adrenaline and noradrenaline compared with baseline concentrations. These findings suggest that the addition of a caudal block to general anaesthesia in children undergoing ilioinguinal herniorrhaphy decreases significantly the neurohormonal responses to surgery.

Summary

Background and objective: A prospective crossover randomized trial was conducted to compare the performance of three commonly used anaesthetic facemasks: a clear plastic ‘Anaesthetic Facemask’ with pre-inflated air cushion, no inflation valve, and for single use (Intersurgical Limited, Wokingham, UK), a clear plastic ‘Air Cushion Mask’ with inflatable air cushion and inflation valve, and for single use (Proact Medical Limited, Kettering, UK), and a black antistatic reusable rubber facemask with pre-inflated air cushion, and no inflation valve (Datex Ohmeda Limited, Hatfield, UK). Methods: After local Ethics Committee approval, written consent was taken from 60 ASA 1 or 2 patients undergoing elective ENT procedures. Following routine intravenous anaesthetic induction and muscle relaxation, a Guedel's oropharyngeal airway was inserted and each of the facemasks tried in a crossover fashion. The degree of chest expansion, the feel on the reservoir bag, the degree of leak around the mask and the overall satisfaction of the anaesthetist were graded and recorded for each facemask. Results: Both the plastic facemasks performed similarly in all the four criteria. The antistatic rubber facemask performed significantly better than the plastic facemasks in these criteria (P < 0.05). Conclusions: This study has shown that the antistatic rubber facemask outperformed the two plastic facemasks during routine induction of general anaesthesia. We hope this will encourage manufacturers to improve disposable facemask design to simulate the antistatic rubber facemask.

An 85-year-old man with undiagnosed eventration of the left hemidiaphragm had an above-knee amputation under epidural anaesthesia. His post-operative course was stormy with two episodes of cardiovascular collapse. On the third post-operative day, rupture of the left hemidiaphragm was diagnosed, the bowel had herniated into the left hemithorax. It is proposed that the left hemidiaphragm ruptured spontaneously because of muscular weakness secondary to the thoracic segmental blockade associated with lumber epidural anaesthesia.

A case of pneumopericardium, without concomitant pneumothorax, resulting from high frequency jet ventilation during laser surgery of the hypopharynx is described. The patient, a four-year-old boy, suffered cardiac arrest as a consequence of the incident. The pneumopericardium was likely to have been caused by obstruction to the expiratory flow during surgery. Other possible explanations for the incident are discussed.