We have compared the efficacy and safety of combined granisetron and droperidol with each anti-emetic alone for preventing post-operative nausea and vomiting after thyroidectomy. In a prospective, randomized, double-blind study, 180 women received granisetron 40 μg kg−1, droperidol 20 μg kg−1, or granisetron 40 μg kg−1 plus droperidol 20 μg kg−1 (n=60 of each) intravenously immediately before induction of anaesthesia. A standard general anaesthetic technique and post-operative analgesia were used. A complete response, defined as no post-operative nausea and vomiting and no need for another rescue anti-emetic, during the first 24 h after anaesthesia occurred in 88%, 60% and 98% of patients who had received granisetron, droperidol and granisetron plus droperidol (P< 0.05; overall Fisher's exact probability test). No clinically important adverse events due to the drugs were observed in any of the groups. In summary, prophylactic use of combined granisetron and droperidol is more effective than each drug alone for the prevention of post-operative nausea and vomiting in female patients undergoing thyroidectomy.

Two patients presented with very different signs of central anticholinergic syndrome following general anaesthesia for which they had received premedication with hyoscine. Both responded dramatically to 1 mg of intravenous (i.v.) physostigmine, which produced a rapid return to a normal level of consciousness. The aetiology of central anticholinergic syndrome is multi-factorial, but the diagnosis should be considered in all patients who demonstrate abnormal post-anaesthetic awakening. It is recommended that 1 mg of intravenous physostigmine is a safe and effective treatment for central anticholinergic syndrome, and that a supply of this important drug must be kept readily available in the recovery area of the operating theatre department.

Summary

Background and objective: Neutrophils are important both for the immunological defence system and for the inflammatory tissue autoinjury mechanism. However, many local anaesthetics impair certain neutrophil functions. The aim was to assess the effects of ropivacaine, bupivacaine and lidocaine on human neutrophils from adult volunteers.

Methods: Chemotaxis, phagocytosis, reactive oxygen species production, intracellular calcium ion ([Ca2+]i) concentrations and protein kinase C activity were measured in the absence and presence of ropivacaine, bupivacaine or lidocaine. The lowest concentrations of the local anaesthetics were similar to those clinically observed in the plasma.

Results: Bupivacaine did not affect any neutrophil function (P > 0.05). Ropivacaine failed to change chemotaxis or phagocytosis, while lidocaine suppressed both these neutrophil functions. Ropivacaine (15, 150 μg mL−1) and lidocaine (20, 200 μg mL−1) impaired neutrophil production of O2−, H2O2 and OH− (P < 0.05) at similar rates (by 7–10%). These same concentrations of ropivacaine and lidocaine suppressed [Ca2+]i elevation. Finally, neither ropivacaine nor bupivacaine inhibited protein kinase C activity, while lidocaine did.

Conclusions: Suppression of the [Ca2+]i response in neutrophils by ropivacaine may represent one of the mechanisms responsible for the impairment of neutrophil functions. It should be emphasized that the inhibitory effects of ropivacaine are minor and are attained only at high concentrations, which may minimize the clinical implication of ropivacaine-associated impairment of reactive oxygen species production. Further studies using in vivo systems are required to identify the inhibitory effects of ropivacaine on reactive oxygen species production in clinical settings.

Background and objective This study compares the effect of oral clonidine vs. hydroxyzine on the haemodynamic and catecholamine responses to microlaryngoscopy.

Methods Thirty-five ASA II-III patients were included in this double-blind randomized trial. The patients received either hydroxyzine 1 mg kg−1 (n=18) or clonidine 3 μg kg−1 (n = 17) for their oral premedication 100 min before an intravenous induction of anaesthesia using propofol (2–3 mg kg−1) and fentanyl (2 μg kg−1). Arterial pressure and heart rate were measured before premedication, and throughout the procedure and recovery. Plasma catecholamine levels were determined before premedication, after induction, and 1.5, 30 and 120 min after laryngoscopy.

Results Mean arterial pressure was significantly lower after clonidine, whereas there was no difference in heart rate and plasma catecholamine levels between the two groups.

Conclusions Clonidine for premedication significantly decreased mean arterial pressure during microlaryngoscopy and the following recovery phase but did not modify the overall haemodynamic response to the suspension microlaryngoscopic nociceptive stimulus.

The aim of the present study was to evaluate the effects of neostigmine as a final anaesthetic manoeuvre on colonic anastomoses. A colonic anastomosis was constructed in 40 Sprague-Dawley rats. The animals were divided into two groups: (1) rats receiving intravenous saline solution (placebo); and (2) rats receiving an intravenous injection of neostigmine. The size of the caecum, and the diameters of the pre-anastomotic and post-anastomotic colon were measured during the operation and 4 days after surgery, when all the animals were sacrificed. At this time, the presence of adhesions was also investigated. Each segment containing an anastomosis was removed, and the bursting pressure and bursting wall tension were determined. Loss of caecum diameter was significantly greater in group 2 than in group 1 (P=0.03). Dilatation and obstruction of the colon were significantly more frequent in group 1 (dilatation, P=0.01; obstruction, P=0.047). Also, consumption of water by group 2 was greater than that by group 1 (P=0.049). No statistically significant differences were found between the diameters of the colon (pre- and post-anastomosis), or with respect to general adhesions and adhesions to the anastomotic line. No significant differences were found between anastomotic resistance (determined in terms of bursting pressure and bursting wall tension) in the two groups. The inclusion of neostigmine in an anaesthetic protocol under experimental setting did not reduce the resistance of colonic anastomoses and did not compromise normal healing. Moreover, obstruction caused by peristaltic weakness might be prevented by the expulsion of stool that is induced by the strong contraction of the colonic smooth muscle.

Background and objective Serum hyaluronate is thought to be an indicator of derangement in hepatocellular integrity, and the change in serum hyaluronate is a useful indicator in various liver disorders. We assessed the changes in serum hyaluronate in patients undergoing coronary artery bypass graft surgery.

Methods Eleven patients scheduled for elective coronary artery bypass graft surgery were studied. An oximetry oxygen saturation catheter was inserted into the right hepatic vein to permit monitoring of hepatic venous oxygen saturation. Perioperative measurements included: haemodynamic variables; systemic oxygen delivery and uptake; arterial, mixed venous and hepatic venous oxygen saturation; arterial and hepatic venous plasma concentrations of lactate, arterial ketone body ratio (ratio of acetoacetate to 3-hydroxybutyrate); and arterial and hepatic venous hyaluronate were measured.

Results Arterial and hepatic venous hyaluronate increased during cardiopulmonary bypass compared with the prebypass period. These increases returned to prebypass values after the cessation of bypass (hepatic venous hyaluronate value at the prebypass period: 26 ± 13 ng mL−1, during bypass: 77 ± 40 ng mL−1; 1 h after bypass: 57 ± 42 ng mL−1; 6 h after bypass: 32 ± 15 ng L−1, 24 h after bypass; 62 ± 21 ng mL−1; mean ± SD, P < 0.05). The arterial and hepatic venous hyaluronate during cardiopulmonary bypass was correlated with total bilirubin and hepatic venous lactate concentrations 6 h after bypass (arterial hyaluronate at cardiopulmonary bypass period vs. total bilirubin at 6 h after bypass; r = 0.793, P = 0.0036, hepatic venous hyaluronate during bypass vs. that at 6 h after bypass; r = 0.795, P = 0.0035).

Conclusions Hepatocellular integrity might be disturbed during cardiopulmonary bypass when propofol anaesthesia is used.

A double-blind, randomized, placebo- and drug-controlled study in which the analgesic efficacy and safety of intravenous (i.v.) tramadol in patients with postoperative pain is reported. One hundred and eighty patients recovering from gynaecological or abdominal surgery were assigned to one of three treatment groups. After titration of an individual loading dose, patients could self-administer tramadol 20 mg, morphine 2 mg or placebo using a patient-controlled analgesia (PCA) device throughout a 48-h period. Criteria of efficacy were a decrease in pain intensity within the first 30 min of at least 20 on a visual analogue scale (VAS) (0 denotes no pain, 100 worst pain imaginable) and satisfactory analgesia in the patient's opinion during the study period. Patients treated with tramadol, morphine and placebo were assessed as responders at 66.7%, 75.0% and 18.3% (P < 0.0001). VAS after the initial bolus were 39.2 ± 22.1, 35.9 ± 21.6 and 50.0±24.2 (P = 0.002), the initial loading dose amounted to tramadol 144.9 ± 51.2 mg, morphine 12.3 ± .1 mg and placebo 17.2 ± 4.9 mL. No serious opioid-related adverse events occurred in the patients given tramadol while two patients given morphine developed an impaired respiratory rate and a decreased oxygen saturation to 80% or less. Tramadol proved to be efficacious for PCA treatment of post-operative pain following gynaecological and abdominal surgery.

Background and objective: Multimodality treatment for patients with locally advanced primary or locally recurrent rectal cancer, including high-dose preoperative external beam radiotherapy, extensive surgery and intraoperative radiation therapy, decreases the local recurrence rates and improves survival. During this aggressive operation, the anaesthesiologist is faced with potential problems such as major transfusion requirements, hypothermia, intraoperative position changes, the need to transport the patient to the intraoperative radiation therapy applicator, and the risks associated with remote monitoring of the patient during the 10 min intraoperative radiation therapy application. The anaesthetic management and perioperative results were evaluated for the anaesthetic results and the complications.

Methods: One-hundred-and-six patients undergoing the multimodality treatment between February 1994 and March 2000 for locally advanced primary (n = 50) and locally recurrent rectal cancer (n = 56) were retrospectively evaluated for their anaesthetic results and complications.

Results: All patients were operated upon using a combination of general and epidural anaesthesia. The average duration of anaesthesia was 6 (range 3–10.5) h and the mean blood loss 3.6 (range 0.4–14) L. All patients recovered well from anaesthesia. Two patients (2%) died in the intensive care unit (34 and 48 days postoperatively) because of adult respiratory distress syndrome following postoperative haemorrhage. Severe haemorrhage during or after the operation was significantly related with the development of adult respiratory distress syndrome (P < 0.0001).

Conclusions: With adequate preoperative assessment and optimalization of the patient's condition, maintaining peroperative haemodynamic stability with the help of adequate remote monitoring, early and fast transfusion, and multidisciplinary communication, anaesthetic complications can be minimized.

The influence of acute moderate haemodilution on the relation between dose and response for rocuronium was evaluated in 60 adult patients, ASA grade I, undergoing elective plastic surgery. The patients were randomly allocated to either the control or the haemodilution group. Following the induction of general anaesthesia, the status of acute moderate haemodilution in the haemodilution group was achieved by draining venous blood, and intravenous infusion of lactated Ringer's solution, 6% dextran or gelofusine, during which the levels of haemoatocrit and haemoglobin dropped from 44% to 27.5% and from 148.3 to 91.3 g L−1, respectively. Neuromuscular function was assessed mechanomyographically with train-of-four stimulation at the wrist every 12 s and the percentage depression of T1 response was used as the study parameter. The relation between dose and response for rocuronium in the two groups was determined by the cumulative dose–response technique. The results showed that the dose–response curve for rocuronium during acute moderate haemodilution was shifted in a parallel fashion to the left and the potency of rocuronium was increased. There were significant differences in ED50, ED90 and ED95 between the two groups. The ED50, ED90 and ED95 of rocuronium in the haemodilution group was decreased by 28.2%, 35.4% and 38.8%, respectively, compared with the control group.

To evaluate arterial (PaCO2), end-tidal (PETCO2) and carbon dioxide tension difference during mechanical ventilation with extratracheal airways, 60 patients ASA physical status I-II, receiving general anaesthesia for minor extra-abdominal procedures were randomly allocated to receive either a cuffed oropharyngeal airway (group COPA, n=30) or a laryngeal mask (group LMA, n=30). The lungs were mechanically ventilated by IPPV using a 60% nitrous oxide and 1–1.5% isoflurane in oxygen mixture (VT8 mL kg−1; RR=12 b min−1; I/E=1/2). After PETCO2 had been stable for at least 10 min after airway placement, haemodynamic variables and PETCO2 were recorded and an arterial blood sample was obtained for measurement of PaCO2. No differences in anthropometric parameters, smoking habit, haemodynamic variables and incidence of untoward events were observed between the two groups. Airway manipulation, to maintain adequate ventilation, was required in only nine patients in the cuffed oropharyngeal airway group (30%)(P < 0.0005); however,in no case was it necessary to remove the designated extratracheal airway due to unsuccessful mechanical ventilation. The mean difference between arterial and end-tidal carbon dioxide partial pressure was 0.4±0.3 KPa in the laryngeal mask group (95% confidence intervals: 0.3–0.5 KPa) and 0.3±0.26 KPa in the cuffed oropharyngeal airway group (95% confidence intervals: 0.24–0.4 KPa) (P =NS). We conclude that in healthy adults who are mechanically ventilated via the cuffed oropharyngeal airway, the end-tidal carbon dioxide determination is as accurate an indicator of PaCO2 as that measured via the laryngeal mask, allowing capnometry to be reliably used to evaluate the adequacy of ventilation.

Medical malpractice has been raised as an important problem in daily practice, while the media and public remain unforgiving to those perceived to have harmed the patients’ life. This article highlights important legal issues related to medical malpractice and summarizes the sources and the nature of potential errors in anaesthesiology practice.

A patient with acute intermittent porphyria was anaesthetized with propofol as part of general an-aesthesia for cholecystectomy. Post-operatively, no clinical sequelae resulted and urinary porphyrins did not exceed pre-operative values.