Managing end-of-life care can be difficult because of the particular nature of intensive care support, which can separate the biological and the biographical aspects of life. Artificial organ support can temporarily delay death but, at the same time, may fail to restore a quality of life that the patient judges acceptable. For this reason, two concepts must be considered: that the mission of the healthcare system should be to care for patients according to their interests and wishes and that quality of care is related above all to the careful commitment of healthcare workers to the patient’s best interests. Keeping these concepts in mind, the rule of the five Cs (competence, collegiality, communication, continuity of care and compassion) might be helpful in the management of end-of-life care. Unfortunately, neither the rule of the five Cs nor the careful use of moral principles in order to promote the patients’ dignity can assure a universally acceptable decision. A reasonable level of ‘moral certainty’, however, might be achieved using a deliberative approach, which provides for the inclusion of all the different subjects involved in the decision-making process (patient, family, doctors, nurses and other carers), in order to reach the best possible decision in a specific situation.

Summary

Background and objective: The transcerebral double-indicator dilution technique is a recently developed method to measure global cerebral blood flow at bedside. It is based on bolus injection of ice-cold indocyanine green dye and simultaneous recording of resulting thermo- and dye-dilution curves in the aorta and the jugular bulb. However, with this method 40 mL of ice-cold solution is administered as a bolus. Therefore, this prospective clinical study was performed to elucidate the effects of repeated administration of indicator on absolute blood temperature and on cerebral blood flow and metabolism.

Methods: The investigation was performed in nine male patients scheduled for elective coronary artery bypass grafting. Absolute blood temperature was measured in the jugular bulb and in the aorta before and after repeated measurements using the transcerebral double-indicator dilution technique.

Results: During the investigated time course, the blood temperature in the jugular bulb, compared to the aorta, was significantly higher with a mean difference of 0.21°C. The administration of an ice-cold bolus reduced the mean blood temperature by 0.06°C in the jugular bulb as well as in the aorta. After the transcerebral double-indicator dilution measurements a temperature recovery to baseline conditions was not observed during the investigated time period. Cerebral blood flow and cerebral metabolism did not change during the investigated time period.

Conclusions: Repeated measurements with the transcerebral double-indicator dilution technique do not affect absolute jugular bulb blood temperatures negatively. Global cerebral blood flow and metabolism measurements remain unaltered. However, accuracy and resolution of this technique is not high enough to detect the effect of minor changes of physiological variables.

We report the successful use of the intubating laryngeal mask airway in a patient with maxillo-facial trauma for whom the facemask and laryngoscope were relatively contraindicated and the fibreoptic scope potentially difficult to use.

Thirty-eight ASA I–III patients undergoing lower abdominal operations were randomly allocated to receive either morphine (group M, patient-controlled analgesia bolus=1 mg of morphine) or tramadol (group T, patient-controlled analgesia bolus=10 mg of tramadol) for post-operative patient-controlled analgesia (PCA) after receiving morphine intraoperatively. There were no between-group differences in the pain, sedation or vomit scores. The nausea scores were significantly higher in group T in the initial 20 h and between 32 and 36 h (P<0.01, 0–4 and 8–12 h; P<0.05, 4–8, 12–16, 16–20 and 32–36 h). The incidence of dizziness was also significantly higher in group T (68.4% vs. 31.6%, group T vs. group M, P<0.05). There was no difference in the overall satisfaction. We conclude that the use of tramadol, compared with morphine, for post-operative PCA after intraoperative loading with morphine is associated with more nausea and dizziness, but with similar sedation, quality of analgesia and patient satisfaction.

Arterial carbon dioxide partial pressure measurements using the NBP-75® microstream capnometer were compared with direct PaCO2 values in patients who were (a) not intubated and spontaneously breathing, and (b) patients receiving intermittent positive pressure ventilation of the lungs and endotracheal anaesthesia. Twenty ASA physical status I–III patients, undergoing general anaesthesia for orthopaedic or vascular surgery were included in a prospective crossover study. After a 20-min equilibration period following the induction of general anaesthesia, arterial blood was drawn from an indwelling radial catheter, while the end-tidal carbon dioxide partial pressure was measured at the angle between the tracheal tube and the ventilation circuit using a microstream capnometer (NBP-75®, Nellcor Puritan Bennett, Plesanton, CA, USA) with an aspiration flow rate of 30 mL min−1. Patients were extubated at the end of surgery and transferred to the postanaesthesia care unit, where end-tidal carbon dioxide was sampled through a nasal cannula (Nasal FilterLine, Nellcor, Plesanton, CA, USA) and measured using the same microstream capnometer. In each patient six measurements were performed, three during mechanical ventilation and three during spontaneous breathing. A good correlation between arterial and end-tidal carbon dioxide partial pressure was observed both during mechanical ventilation (r = 0.59; P = 0.0005) and spontaneous breathing (r = 0.41; P = 0.001); while no differences in the arterial to end-tidal carbon dioxide tension difference were observed when patients were intubated and mechanically ventilated (7.3 ± 4 mmHg; CI95: 6.3–8.4) compared to values measured during spontaneous breathing in the postanesthesia care unit, after patients had been awakened and extubated (6.5 ± 4.8 mmHg; CI95: 5.2–7.8) (P = 0.311). The mean difference between the arterial to end-tidal carbon dioxide tension gradient measured in intubated and non-intubated spontaneously breathing patients was 1 ± 6 mmHg (CI95: -11–+13). We conclude that measuring the end-tidal carbon dioxide partial pressure through a nasal cannula using the NBP-75® microstream capnometer provides an estimation of arterial carbon dioxide partial pressure similar to that provided when the same patients are intubated and mechanically ventilated.

Summary

Background and objectives: This study was designed to investigate the role of nitric oxide on catalepsy induced by fentanyl and haloperidol. Methods: Male albino mice were treated either with fentanyl (0.1–0.2 mg kg−1, s.c.) or haloperidol (0.5–2 mg kg−1, i.p.). The non-selective nitric oxide synthase inhibitor, NG-nitro-l-arginine (10 mg kg−1, i.p.), selective neuronal nitric oxide synthase inhibitor, 7-nitroindazole (3 mg kg−1, i.p.), and nitric oxide donors, l-arginine (30–300 mg kg−1, i.p.) and d-arginine (30 mg kg−1, i.p.), were applied 20 min prior to fentanyl or haloperidol injection. A μ-opioid receptor antagonist naloxone (1 mg kg−1, i.p.) was also given in some groups. The cataleptic status of mice was assessed by placing animals in a rearing position in the cage. If the mouse maintained cataleptic posture for more than 20 s, it was scored as cataleptic and duration of catalepsy was expressed in terms of minutes. Results: Both NG-nitro-l-arginine and 7-nitroindazole prolonged fentanyl-induced catalepsy (fentanyl: 3.6 ± 0.8 min; fentanyl + NG-nitro-l-arginine: 77.4 ± 14.6 min, fentanyl + 7-nitroindazole: 56.0 ± 10.4 min; n = 6; P < 0.01). This effect was reversed by l-arginine and naloxone, but not by d-arginine. Nitric oxide synthase inhibitors also prolonged the cataleptic action of haloperidol but to a lesser extent (haloperidol: 72.0 ± 6.3 min; haloperidol + NG-nitro-l-arginine: 98.5 ± 6.3 min, haloperidol + 7-nitroindazole: 89.6 ± 2.2 min; n = 6; P < 0.05). The prolongation of haloperidol-induced catalepsy with nitric oxide synthase inhibitors was not reversed by l-arginine. Conclusion: These results suggest a common mechanism between μ-opioid receptors and the nitric oxide system in the development of fentanyl-induced catalepsy in mice different from haloperidol-induced catalepsy.

In this prospective study techniques for the subcutaneous ring block of the penis and subpubic block of the penis for analgesia after circumcision were compared. Forty-five boys having circumcision as day-case patients were allocated randomly to have either a subcutaneous ring block or a subpubic penile block. The blocks were inserted after induction of anaesthesia but before surgery. Pain scores at 15, 30, 45 and 60 min post-operatively were recorded. Side effects and analgesic requirements in hospital were recorded post-operatively. Analgesia (morphine, paracetamol or diclofenac) was given depending on the pain score. One patient was withdrawn from the study. Four of the 24 boys who had subpubic penile blocks and nine of the 16 boys who had subcutaneous ring blocks were given morphine for post-operative pain (P = 0.015). The surgeons complained about oedematous tissues in three patients, all of whom had had subcutaneous ring blocks. The subpubic penile block provided significantly better analgesia than the subcutaneous ring block of the penis.

Background and objective: Volatile anaesthetic agents are known to influence neutrophil function. The aim was to determine the effect of chronic occupational exposure to volatile anaesthetic agents on the rate of neutrophil apoptosis among anaesthetists. To test this hypothesis, we compared the rate of neutrophil apoptosis in anaesthetists who had been chronically exposed to volatile anaesthetic agents with that in unexposed volunteers.

Methods: Venous blood (20 mL) was withdrawn from 24 ASA I-II volunteers, from which neutrophils were isolated, and maintained in culture. At 1, 12 and 24 h in culture, the percentage of neutrophil apoptosis was assessed by dual staining with annexin V-FITC and propidium iodide.

Results: At 1 h (but not at 12 and 24 h) in culture, the rate of neutrophil apoptosis was significantly less in the anaesthetists – 13.8 (12.9%) versus 34.4 (12.1%) (P = 0.001).

Conclusions: Chronic occupational exposure to volatile anaesthetic agents may inhibit neutrophil apoptosis. This may have implications for anaesthetists and similarly exposed healthcare workers in terms of the adequacy of their inflammatory response.

Extracorporeal membrane oxygenation is the recommended treatment for fulminant pulmonary failure due to varicella pneumonia. However, in pregnancy fetal viability during extracorporeal membrane oxygenation is generally poor resulting in either therapeutic or spontaneous abortion. The present case is to our knowledge the first report on the treatment with nitric oxide to improve oxygenation in a pregnant woman with fulminant pulmonary failure due to varicella pneumonia. Adding 20 parts per million nitric oxide to the inspiratory gas increased arterial oxygen saturation from 75 to 88%, and it could be kept at this level. Due to a vaginal bleeding, an emergency Caesarean section was performed with successful outcome for the fetus. The mother started to improve after delivery and could be weaned from nitric oxide after 5 days. We conclude that inhalation of nitric oxide may be a good alternative to extracorporeal membrane oxygenation in the treatment of fulminant pulmonary failure due to varicella pneumonia in pregnancy.

A randomized crossover study was designed using the chronically instrumented pregnant sheep preparation to study the possible effects of epidural injection of adrenaline as a single compound on the circulation of mother and fetus. Three consecutive identical doses of adrenaline were administered epidurally with a 30 min interval between treatments. In a randomized crossover fashion two dosages (10 and 15 μg) were tested on different days. The day after the last epidural experiment the same doses of adrenaline were given intravenously (i.v.). Between the two i.v. doses a 30 min interval was allowed for values to return to baseline. Twenty-seven experiments were performed in eight ewes. Epidural administration of adrenaline did not affect maternal mean arterial pressure, maternal heart rate, uterine blood flow, fetal mean arterial pressure, fetal heat rate, or maternal and fetal blood gases and acid-base status. After i.v. administration of adrenaline the uterine blood flow decreased in a dose-dependent fashion, but the other haemodynamic variables were not affected. In conclusion, this study indicates that consecutive epidural injections of adrenaline have no significant effect on maternal and fetal haemodynamic responses, uterine blood flow, blood gases and acid–base status in the gravid ewe. However, an i.v. injection of 10 or 15 μg adrenaline decreases the uterine blood flow and could compromise the fetus.

Summary

Background and objective: Epidural analgesia is widely used for abdominal surgery due to the properties of ‘stress-free’ anaesthesia and superior pain control. Nevertheless, sympathomimetics are known to antagonize inflammation. The present study was performed to investigate if epidural local anaesthetics caused increased local oedema formation.

Methods: Thirty Dansk Landrace pigs were randomized into three groups: epidural bupivacaine, epidural morphine or intravenous (i.v.) fentanyl. All animals were anaesthetized with isoflurane and i.v. midazolam and received an identical fluid regimen. Six small bowel resections were performed over a 3-h period and during the following 3 h the anastomoses were resected. Primary end-points were water content in small bowel and mesentery samples before and after gut anastomosis, lymph flow and urine production.

Results: The water content in the small bowel samples was not changed by surgery or by the different anaesthetic protocols. In the mesenteric tissue, there was a highly significant increase in water content of the post-anastomotic samples compared to pre-anastomotic samples (P < 0.001) and a significant time treatment interaction was revealed (P < 0.05) suggesting an increase in oedema formation in the epidural local anaesthetic group. Lymph flow did not change during the experiments and there were no significant differences between the groups (P = 0.80). The mean total urine output was 44% higher in the epidural morphine group compared to the local anaesthetic group (P = 0.17).

Conclusions: Surgery did not increase gut wall water content, but acute oedema formation resulted in the peri-resectional mesenterial tissue, more prominently so in the bupivacaine group.

Summary

Background and objective: Recently published guidelines for checking anaesthetic equipment do not contain specific advice on how to check the correct functioning of the capnograph before inducing anaesthesia. Methods: We undertook a postal survey of UK consultant (physician) anaesthetists to establish what methods for checking the capnograph are currently in use. Two hundred and two questionnaires were sent to consultants in different hospitals and 163 returned, a response rate of 81%. Results: 52.1% consultants of check the capnograph themselves. Of these, 55.3% use their own expired breath to confirm a response to carbon dioxide. Other methods used by consultant anaesthetists to check capnograph function include the machine self-test (16.5%), visual checks of the capnograph and sampling tubing (10.3%), and sampling of patient expired carbon dioxide (7.1%). Conclusion: The most common method for testing capnograph function among consultant anaesthetists and their assistants in the UK is the direct measurement of exhaled breath.

Background and objective: Epidural analgesia is the most effective method for pain relief during labour. The aim was to elucidate the efficacy of ropivacaine 0.05% and bupivacaine 0.05%, which were both combined with fentanyl 0.00015% to provide analgesia in labour.

Methods: Forty nulliparous females were enrolled into the study. After insertion of an epidural catheter, patients were randomly assigned into two groups. Once the os uteri had dilated to 4–5 cm, a bolus of bupivacaine 0.125% 10 mL + fentanyl 50 μg (1 mL) in Group 1 patients, and ropivacaine 0.125% 10 mL + fentanyl 50 μg (1 mL) in Group 2 patients was administered via the epidural catheter. Then, patient-controlled epidural analgesia was started with a basal infusion of bupivacaine 0.05% 10 mL h−1 + fentanyl 0.00015% 1.5 μg mL−1 in Group 1, and ropivacaine 0.05% + fentanyl 1.5 μg mL−1 in Group 2. When needed, a 10 mL bolus infusion could be given and the lockout time was 20 min. Maternal and fetal haemodynamic variables were monitored before induction and subsequently at 5 min intervals. Using a visual analogue scale assessed the degree of pain.

Results: Maternal haemodynamic variables and Apgar scores were not different between the two groups. The second stage of the labour was shorter in Group 2 (P < 0.01). There were no significant differences in patients’ assessment of motor block or mode of delivery between groups.

Conclusions: An epidural infusion (10 mL h−1) of bupivacaine 0.05% or ropivacaine 0.05% together with fentanyl 1.5 μg mL−1 provided good and safe analgesia during labour.

Background and objective The efficiency of intraoperative autotransfusion in scoliosis surgery is poorly known but needs to be evaluated, not least because of the large blood losses in these patients. This is a retrospective analysis of transfusion requirements of 43 such patients.

Methods Records from 43 patients were studied. During surgery, the shed blood was salvaged and washed in an autotransfusion device (AT1000 Autotransfusion Unit®) and a suspension of red cells was reinfused.

Results Fifty-eight per cent of the intraoperative blood loss was salvaged. The total blood loss during the patients' hospital stay was calculated from the haemoglobin balance; 24% of this loss was salvaged by the device. Moreover, 36 of the patients needed allogeneic blood transfusion.

Conclusion The efficiency of the autotransfusion device was relatively low in relation to the total extravasation, mainly because the postoperative blood loss is substantial.

This article will discuss the challenges related to the demonstration of the efficacy of monitoring in an intensive care environment. It will address interpretation, therapeutic intervention, sample size and compare efficacy to effectiveness in the context of the developing field of neurocritical care.