Background and objective: Induction of general anaesthesia in combination with positive-pressure ventilation is often associated with a significant decrease of arterial pressure. A decreased preload may contribute to this phenomenon. The aim was to investigate whether a change in cardiac filling occurs following the induction of general anaesthesia with sufentanil under typical clinical conditions.

Methods: Fifteen patients scheduled for elective coronary bypass grafting were studied immediately before surgery. In addition to standard monitors, a transpulmonary double-indicator dilution technique measured in vivo intrathoracic blood volume, global end-diastolic volume and total circulating blood volume. For induction of anaesthesia 2 μg kg−1 sufentanil was given. Measurements were performed awake and after the induction of anaesthesia, intubation and mechanical ventilation of the lungs.

Results: To maintain arterial pressure during the induction period within −20% of baseline pressure, on average 22 ± 6 mL kg−1 crystalloids and 8 ± 6 mL kg−1 colloids were given. Despite these amounts of fluid, cardiac filling was decreased, whereas circulating blood volume increased significantly. Both central venous pressure and pulmonary capillary wedge pressure increased.

Conclusions: Induction of general anaesthesia with positive-pressure ventilation is regularly associated with a blood volume shift from intra- to extrathoracic compartments. Even in low-dose opioid monoanaesthesia with sufentanil – often regarded as relatively inert in haemodynamic terms – the phenomenon could be demonstrated as the primary cause of the often-observed decrease of arterial pressure. It seems, therefore, rationally justified to restore cardiac filling by generous administration of intravenous fluids, at least in patients with unaffected cardiac pump function. During induction of anaesthesia, central venous pressure and pulmonary capillary wedge pressure do not reliably indicate cardiac filling.

Summary

Background: Lidocaine has actions potentially of benefit during ischaemia–reperfusion. Neutrophils and endothelial cells have an important role in ischaemia–reperfusion injury.

Methods: Isolated human neutrophil CD11b and CD18, and human umbilical vein endothelial cell (HUVEC) ICAM-1 expression and supernatant IL-1β concentrations in response to hypoxia–reoxygenation were studied in the presence or absence of different concentrations of lidocaine (0.005, 0.05 and 0.5 mg mL−1). Adhesion molecule expression was quantified by flow cytometry and IL-1β concentrations by ELISA. Differences were assessed with analysis of variance and Student–Newman–Keuls as appropriate. Data are presented as mean ± SD.

Results: Exposure to hypoxia–reoxygenation increased neutrophil CD11b (94.33 ± 40.65 vs. 34.32 ± 6.83 mean channel fluorescence (MCF), P = 0.02), CD18 (109.84 ± 35.44 vs. 59.05 ± 6.71 MCF, P = 0.03) and endothelial ICAM-1 (146.62 ± 16.78 vs. 47.29 ± 9.85 MCF, P < 0.001) expression compared to normoxia. Neutrophil CD18 expression on exposure to hypoxia–reoxygenation was less in lidocaine (0.005 mg mL−1) treated cells compared to control (71.07 ± 10.14 vs. 109.84 ± 35.44 MCF, P = 0.03). Endothelial ICAM-1 expression on exposure to hypoxia–reoxygenation was less in lidocaine (0.005 mg mL−1) treated cells compared to control (133.25 ± 16.05 vs. 146.62 ± 16.78 MCF, P = 0.03). Hypoxia–reoxygenation increased HUVEC supernatant IL-1β concentrations compared to normoxia (3.41 ± 0.36 vs. 2.65 ± 0.21 pg mL−1, P = 0.02). Endothelial supernatant IL-1β concentrations in lidocaine-treated HUVECs were similar to controls.

Conclusions: Lidocaine at clinically relevant concentrations decreased neutrophil CD18 and endothelial ICAM-1 expression but not endothelial IL-1β concentrations.

Summary

Background and objective: Intraperitoneal administration of a local anaesthetic in combination with an opioid, for the relief of postoperative pain, has already been reported except after laparoscopic cholecystectomy. This study was aimed at assessing the analgesic effect of the intraperitoneal administration of bupivacaine and morphine in patients undergoing laparoscopic cholecystectomy.

Methods: At the end of laparoscopic cholecystectomy, in a double-blind, randomized manner, one of the following injections was given intraperitoneally. There were 30 patients in each group: Group 1, physiological saline 30 mL; Group 2, bupivacaine 0.25% 30 mL; Group 3, bupivacaine 0.25% 30 mL plus morphine 2 mg. In addition, Group 2 received 2 mg intravenous (i.v.) morphine in 2 mL saline, and Groups 1 and 3, 2 mL saline intravenously. Patients' postoperative pain was evaluated using a visual analogue scale and a verbal rating score. The postoperative analgesic requirement was assessed by the total dose of metamizol administered by an i.v. patient-controlled analgesia (PCA) device. Pain, vital signs, supplemental analgesic consumption and side-effects were recorded for all patients for 24 h.

Results: There were no differences between the three groups regarding pain scores (at rest and coughing) during the study except in the first 2 h, when scores were lower for patients receiving intraperitoneal bupivacaine plus i.v. morphine (P < 0.05). Supplemental consumption of metamizol was significantly lower (P < 0.05) in Group 3 than in Group 1 during the first 6 h after surgery. However, the cumulative doses of metamizol were also lower in Group 2 than in Groups 1 and 3 over the entire study (2025 ± 1044 mg vs. 4925 ± 1238 and 4125 ± 1276 mg; P < 0.05).

Conclusions: In patients undergoing laparoscopic cholecystectomy, the intraperitoneal administration of morphine plus bupivacaine 0.25% reduced the analgesic requirements during the first 6 postoperative hours compared with the control group. However, the combination of intraperitoneal bupivacaine 0.25% and i.v. morphine was more effective for treatment of pain after laparoscopic cholecystectomy.

Neuromuscular complications encountered in intensive care can be due to peripheral nerves (polyneuropathies), muscles (myopathies), neuromuscular end-plate (transmission deficit) or a combination of these. Neurophysiopathological tests that enable us to diagnose and maybe differentiate between these causes are essentially electroneurographs and electromyographs. These assess, either directly or indirectly, the integrity of the peripheral system, both sensory (centripetal afferent pathways) and motor (lower motor neurones, neuromuscular junction, muscle membrane and contractile substrate). Electrical activity in the muscle is measured using a special device (an electromyograph) comprising preamplifiers, a computer with special programmes and algorithms for analysing, digitalizing, amplifying and filtering the recorded signal and a monitor on which to visualize the on-line trace. The machine also has speakers. These serve to recognize and identify the physiological events being recorded as they make such unusual, individual sounds. An electric stimulator with constant current can be used to stimulate branches of superficial nerves (motor, sensory or mixed) so that electric conduction speed can be studied and the sensory or motor response analysed. The results can be saved on a hard disc or on any magnetic or digital support, viewed off-line or even printed.

Background and objective: The study was designed to evaluate whether the administration of sevoflurane in 100% oxygen for anaesthesia during Caesarean section would improve fetal and neonatal oxygenation compared with the administration of sevoflurane with 50% nitrous oxide in oxygen.

Methods: The randomized, single-blind controlled study examined 24 mothers, ASA I-II, at term undergoing Caesarean section who were allocated to receive sevoflurane in either 100% oxygen (n = 13) or 50% nitrous oxide in oxygen (n = 11). General anaesthesia was induced in both groups with thiopental 4–5 mg kg−1 followed by succinylcholine 1.5 mg kg−1 to facilitate tracheal intubation. Parturients received sevoflurane given either in 100% O2 or in a 50 : 50 nitrous oxide and oxygen mixture, using 0.5-1.0% progressive incremental dosing up to 1.5–2.0 MAC. Non-invasive fetal oxygen saturation was measured between induction to delivery, and umbilical artery and vein PaO2 were evaluated at birth.

Results: Intraoperative fetal oxygen saturation increased in all patients after maternal 100% oxygen administration (P < 0.01). Maternal hyperoxygenation significantly increased the umbilical vein and umbilical artery PaO2 and the umbilical artery SaO2 at birth (P < 0.0001).

Conclusions: Maternal hyperoxygenation significantly improves fetal as well as neonatal oxygenation.

Summary

Background and objective: Continuous spinal analgesia (CSA) offers considerable pain relief, and has been used in various procedures such as for surgery and cancer pain control. In Japan, portable and disposable infusion kits are increasingly employed for continuous epidural analgesia and CSA. In CSA, the use of a microcatheter is expected to reduce the incidence of spinal headache previously encountered with larger catheters. However, the flow rate of disposable infusion kits is reduced when used in conjunction with a microcatheter.

Methods: This study aimed to investigate the influence of catheter length on the flow rate of two different devices: 20- or 91-cm 28-G microcatheters connected to balloon- or syringe-type infusion pumps were examined (50 mL, 1 mL h−1). There were four groups each of 10 experiments: Group A: balloon-type infuser, 91 cm catheter; Group B: balloon-type infuser, 20 cm catheter; Group C: syringe-type infuser, 91 cm catheter; Group D: syringe-type infuser, 20 cm catheter.

Results: The mean flow rate in Group A was significantly less than that in Group B and the mean flow rate in Group C was significantly less than Group D (P < 0.05).

Conclusion: These results indicated that the use of a shorter microcatheter achieves a better flow rate during CSA.

Lignocaine is a suitable and safe agent for intravenous regional anaesthesia (IVRA) with rapid onset of good surgical anaesthesia. The onset time of the local anaesthetic action of lignocaine was 11.2±5.1 min. Satisfactory surgical conditions, evidenced by good sensory blockade were achieved within 20 min, and no additional analgesics were required. There was no trend towards a fixed sequence, radial, median and ulnar in the development of sensory blockade. No patient exhibited objective symptoms of toxicity, either local or systemic, after release of the tourniquet, nor were there any subjective complaints. No changes in blood pressure, heart rate or oxygen saturation were observed at any time during the procedure, or after deflation of the tourniquet. After releasing the tourniquet lignocaine is rapidly and biexponentially eliminated, with a t1/2a of 4.3±2.1 min and a t1/2β of 79.1±31.2 min. Total body clearance was 0.86 ± 0.39L min−1. Eight patients showed rapid release of lignocaine from the exsanguinated area. In two patients the systemic plasma concentration of lignocaine increased more slowly than in the remaining eight. This can be explained by a greater degree of lignocaine absorbtion in the tissues of the arm. Pharmacokinetic constants after rapid and slow absorption were calculated.

The recruitment of leukocytes to the sites of inflammation and leukocyte-derived inflammatory mediators contributes to the development of tissue injury associated with inflammatory diseases. The first step in the pathogenesis of inflammatory conditions is adhesion of circulating leukocytes to activated vascular endothelial cell in the inflamed tissues and subsequent transmigration through the endothelial cells. During these processes, leukocytes are activated to secrete a variety of substances such as growth factors, chemokines and cytokines, complement components, proteases, nitric oxide, and reactive oxygen metabolites, which are considered to be one of the primary sources of the tissue injury. Prevention or reduction of leukocyte-endothelial cell adhesion often results in a profound attenuation of the microvasculature and parenchymal cell dysfunction in various animal models of human inflammatory diseases. It has been shown that all aspirin-like non-steroidal anti-inflammatory agents share at least one characteristic in that all of these agents diminish the adhesive interactions required for the accumulation of leukocytes at the site of inflamed tissue. The challenge for future investigations will need to be carefully examined: the relations between leukocyte and endothelial cell interactions, the mechanisms of activation of leukocytes and endothelial cells, and the components of the signaling pathways. Information related to these topics will allow a better understanding of the role of leukocytes in inflammatory tissue injury and the development of novel therapeutic strategies.

Forty-two children (aged 27–16 years) were randomly assigned to receive either sevoflurane (n=21) or halothane (n=21) in nitrous oxide/oxygen. After premedication with midazolam, anaesthesia was induced by facemask and the anaesthetic concentration was increased until loss of eyelash reflex (sevoflurane, 6%; halothane, 2.5%). Thereafter, 1–1.5 MAC of the inhalational agents were maintained until skin closure. Intra-operative analgesia was provided either by intermittent intravenous (i.v.) bolus doses of fentanyl (2–3 μg kg−1) or by a regional blockade. Induction was smooth and the time to loss of eyelash reflex was slightly shorter with sevoflurane than with halothane, the difference not quite reaching statistical significance (P=0.06). In both groups, heart rate remained stable and blood pressure decreased significantly during induction. Haemodynamic parameters remained stable during anaesthetic maintenance; no cardiac dysrhythmias were observed. Emergence time with sevoflurane was 12.9 min vs. 16.3 min with halothane, but this difference was not statistically significant. It is concluded that sevoflurane is as suitable for paediatric patients as halothane. The slightly faster emergence time offered by sevoflurane over halothane was of no clinical significance in the present study.

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.

Background and objective: The addition of alfentanil or atracurium to lidocaine solution for intravenous regional anaesthesia of the arm may have advantages with respect to improved muscle relaxation and better analgesia. The study investigates these possibilities.

Methods: We investigated 33 patients. Plain lidocaine solution was administered to Group 1 (n = 11). Alfentanil (0.5 mg) and atracurium (3 mg) were added to the lidocaine solution in Groups 2 (n = 11) and 3 (n = 11), respectively. The onset of sensory and motor block, intra- and postoperative pain scores, and the duration of postoperative analgesia were evaluated.

Results: There was a significant difference in the speed of the onset of sensory block in the hand, but not at the tourniquet site. The onset of the motor block, intra- and postoperative pain scores, and the duration of postoperative analgesia were similar in all groups.

Conclusions: No clinical benefits of adding alfentanil or atracurium to lidocaine solution for intravenous regional anaesthesia of the arm could be shown.

To use end-tidal PCO2 as a non-invasive estimate of arterial PCO2, one adds a nominal value, representing the arterial–end-tidal PCO2 difference. How much does one add? We hypothesized that, halving the ventilator rate and simultaneously doubling tidal volume, the immediate change in end-tidal PCO2 would be proportional to the original arterial-end-tidal PCO2 difference. We ventilated 31 patients at 20 breaths per minute (bpm), sampled arterial blood, and changed the rate to 10 bpm. The change in end-tidal PCO2 was, as hypothesized, positively correlated to the original arterial–end-tidal difference at 20 bpm (r = 0.64). End-tidal PCO2 increased in 23 patients. Thus, in theory, this method could offer some improvement in the estimate of arterial PCO2 from end-tidal. However, because of the considerable spread of values, a separate study is needed for verification