We report the case of a 33-year-old woman who developed a dense hemiplegia immediately after an uncomplicated general anaesthetic for diagnostic laparoscopy. She had a history of recurrent hemiplegic migraine with a strong family history. Her migraine was normally associated with visual disturbances and a unilateral headache followed by a left-sided weakness such that she was unable to walk. Symptoms would last up to 24 h. Her post-operative state was atypical of her normal migraine, in that she had no headache or visual disturbance and initially all four limbs were affected.

We present a case of a 25-year-old woman undergoing resection of a large phaeochromocytoma at 16-weeks gestation.

Forty patients (> 65 years) undergoing hip arthroplasty or peripheral vascular surgery both associated with high risk for post-operative myocardial ischaemia were randomized to receive either spinal or general anaesthesia. Ambulatory ECG recording (Holter) until the third post-operative morning, a daily 12-lead ECG and serum creatine kinase and troponine concentrations were obtained. The number of ischaemic episodes, total duration of ischaemia and ischaemic minutes per hour were noted for each patient peri-operatively. Sixteen of the patients (40%) had post-operative myocardial ischaemia. An intra-operative increase in the plasma concentration of norepinephrine but not epinephrine was detected in the patients who later developed post-operative myocardial ischaemia. The increase in plasma norepinephrine concentrations correlated with the decrease in core temperature. The type of anaesthesia had no effect on the incidence of myocardial ischaemia during or after surgery. Our results suggests that intra-operatively decreased core temperature and the increase in plasma concentration of norepinephrine probably caused peripheral vasoconstriction leading to latent cardiac dysfunction. These events should be avoided in the patients at risk of post-operative cardiac ischaemia.

The rapid onset and offset of rapacuronium can be explained from its pharmacokinetic and pharmacodynamic characteristics. A unique property of rapacuronium is its high value for ke0, indicating a rapid access to the receptor site. The reason for this high ke0 may be related to the low intrinsic potency of rapacuronium, but this is not yet fully clarified.

Clevidipine is a new lipophilic, ultra-short acting 1,4-dihydropyridine calcium channel antagonist for intraoperative use. Because sarcolemnal calcium currents are involved in the mechanism of action of anaesthetics we questioned whether clevidipine alters the potency of volatile anaesthetics. We studied the effects of clevidipine on minimal alveolar concentration and the time to awaken from isoflurane anaesthesia. Sprague-Dawley rats were anaesthetized with isoflurane, and were allocated to one of four treatments prior to minimal alveolar concentration determination: (a) saline control; (b) clevidipine 20 nmol kg−1 min−1; (c) clevidipine 40 nmol kg−1 min−1; (d) clonidine 1 μg kg−1 – positive control. Ten mongrel dogs were anaesthetized with isoflurane and received a continuous infusion of clevidipine 6 nmol kg−1 min−1 or the solvent (Intralipid 20% – control). After 2 h of steady-state anaesthesia, minimal alveolar concentration awake and the time to awakening were recorded. Clevidipine reduced minimal alveolar concentration to a small but statistically significant extent (from 1.40±0.16 control to 1.23±0.13 vol% with 20 nmol kg−1 min−1 and to 1.27±0.12 vol% with 40 nmol kg−1 min−1; mean±SD; P < 0.05) in rats. Clonidine reduced minimal alveolar concentration to 0.90±0.17 vol% (mean± SD; P < 0.05). Minimal alveolar concentration awake and the duration of sleep were not affected by clevidipine in dogs. Clevidipine mildly reduces miinimal alveolar concentration of isoflurane but does not prolong the duration of sleep and does not affect minimal alveolar concentration awake after a 2-h steady-state isoflurane anaesthesia.

Summary

Background and objective: The visual analogue scale (VAS) is considered as the gold standard method for postoperative pain assessment. Nevertheless, in some clinical situations, this method may not be reliable. We performed an observational study to assess the use of the VAS and other pain scales by nurses in the postanaesthesia care unit.

Methods: We studied the reasons for not using the VAS and asked if it may be less appropriate in certain age groups.

Results: Among 600 patients included in the study (16% = 70 yr), nurses used the VAS in 53%, the numerical rating scale in 30%, the verbal rating scale in 12% and the behavioural scale in 5%. In 43% of the assessments, nursed did not use the VAS; the most frequently cited reason was related to their preference for other methods. In 54% of the assessments, the reason for not using the VAS was related to the patients, mainly when they were in too much pain to use it (22%). When the patient was in too much pain, the numerical rating scale was chosen in 54% and the behavioural scale in 27%. There was no difference between young patients and elderly patients.

Conclusions: Although the VAS is the standard method to assess pain, the nurses preferred using the numerical rating scale, both spontaneously or when VAS assessment was not possible.

Summary

Background and objective: In some situations, the use of muscle relaxants (neuromuscular blocking drugs) are undesirable or contraindicated. We compared intubating conditions without muscle relaxants in premedicated patients receiving either alfentanil 40 μg kg−1 or remifentanil 2, 3 or 4 μg kg−1 followed by propofol 2 mg kg−1.

Methods: In a randomized, double-blind study, 80 healthy patients were assigned to one of four groups (n = 20). After intravenous atropine, alfentanil 40 μg kg−1 or remifentanil 2, 3 or 4 μg kg−1 were injected over 90 s followed by propofol 2 mg kg−1. Ninety seconds after administration of the propofol, laryngoscopy and tracheal intubation were attempted. Intubating conditions were assessed as excellent, good or poor on the basis of ease of lung ventilation, jaw relaxation, laryngoscopy, position of the vocal cords, and patient response to intubation and slow inflation of the endotracheal tube cuff.

Results: Seven patients who received remifentanil 2 μg kg−1 and one patient who received remifentanil 3 μg kg−1 could not be intubated at the first attempts. Excellent intubating conditions (jaw relaxed, vocal cords open and no movement in response to tracheal intubation and cuff inflation) were observed in those who received either alfentanil 40 μg kg−1 (45% of patients) or remifentanil in doses of 2 μg kg−1 (20%), 3 μg kg−1 (75%) or 4 μg kg−1 (95%). Overall, intubating conditions were significantly better (P < 0.05), and the number of patients showing excellent conditions were significantly higher (P < 0.05) in patients who received remifentanil 4 μg kg−1 compared with those who received alfentanil 40 μg kg−1 or remifentanil 2 μg kg−1. No patient needed treatment for hypotension or bradycardia.

Conclusions: Remifentanil 4 μg kg−1 and propofol 2 mg kg−1 administered in sequence intravenously provided good or excellent conditions for tracheal intubation in all patients without the use of muscle relaxants.

Background and objective: The removal of the non-functioning liver in cases of fulminant liver failure has been advocated by some authors as a means of improving haemodynamic instability and acid-base disturbances associated with acute liver failure.

Methods: The aim of the present experimental study was to investigate whether maintaining a non-functioning liver is preferable over removing it in terms of haemodynamic variables, after acute hepatic failure has been surgically induced. Twenty Landrace pigs were used in the study. All of them underwent portocaval anastomosis and ligation of the hepatic artery. After an 18-h period and with biochemical indices of fulminant hepatic failure clearly demonstrated, the animals were randomly assigned to one of two groups: in 10 pigs (Group A) the ischaemic liver was left in situ and no further surgical intervention was undertaken. The other 10 (Group B) underwent total hepatectomy. Haemodynamic monitoring was the same in both groups. No inotropes were administered throughout the whole period of observation.

Results: Haemodynamic deterioration was observed in the hepatectomized pigs (Group B) whereas the group with the ischaemic liver in situ (Group A) remained stable in terms of the haemodynamic variables evaluated until the end of the experiment. (Cardiac index in Group A 7.59 ± 1.25 Lmin−1 m-2 vs. 2.92 ± 0.68 Lmin−1 m−2 in Group B, P < 0.05.)

Conclusions: The concept of salvage hepatectomy in cases of acute liver failure should be redefined since there seems to be some experimental evidence that it may not be as beneficial as originally thought.

The effect of the addition of clonidine 2 μg kg−1 to prilocaine 0.57% for intravenous regional anaesthesia (IVRA) in the arm was investigated in 56 healthy patients using a randomized, double-blind study. The characteristics of the sensory and motor block, quality of analgesia, development of post-operative pain sensations and haemodynamic variables were studied in three groups (IVRA with prilocaine, IVRA with prilocaine and clonidine, IVRA with prilocaine and systemic application of clonidine at tourniquet release). There were no significant differences between the groups concerning the onset and recovery characteristics of sensory and motor blockade, post-operative pain or side effects. In those patients receiving clonidine, mean arterial pressure decreased significantly (24–28%, respectively) after tourniquet release, while heart rate remained unchanged. Clonidine as an adjunct to prilocaine seems to be of limited benefit during and after intravenous regional anaesthesia.

Summary

Background and objective: Isoflurane has been shown to mimic ischaemic preconditioning (IPC). The protective effect of IPC, or applying isoflurane or perfusion with the ‘push-pull’ complex zinc–desferrioxamine (Zn–DFO) in the canine heart, was investigated.

Methods: Thirty minutes after salicylate administration (100 mg kg−1) the heart was exposed. All dogs were subjected to a 10 min left anterior descending artery occlusion followed by 2 h of reperfusion. In Group I (n = 9) isoflurane (2.5%) was administered 10 min prior to and during ischaemia. In Group II (n = 8), IPC was elicited by 5 min coronary artery occlusion, followed by 5 min of reperfusion, prior to the 10 min ischaemia. In Group III (n = 9) Zn–DFO (2.5 mg kg−1) was given 10 min prior to ischaemia. The effects of these interventions were compared to control (n = 10). Coronary sinus blood concentrations of salicylate, 2,3-dihydroxybenzoic acid (DHBA), lactate, pH and oxygen content were monitored.

Results: In the control group, 2,3-DHBA increased by 32% above the pre-ischaemic value (P < 0.05). In contrast, in the IPC hearts, a significant decrease in the production of 2,3-DHBA was observed (40% lower than baseline, P < 0.01). In the isoflurane group only a 13% (and non-significant) decrease was noticed. In the Zn–DFO group a 33% decrease was found (P < 0.01). The increase in lactate concentrations in the IPC and Zn–DFO groups was significantly smaller than that of control and isoflurane groups.

Conclusions: IPC protected the heart against the deleterious effects of reperfusion, possibly by amelioration of the level of oxygen-derived reactive species, and the complete inhibition of reactive hydroxyl radical production. Isoflurane did not prove to be as effective in reducing the free radical damage.

An 86-year-old man on whom a transurethral resection of prostate was performed under spinal anaesthesia developed profound bradycardia and hypotension with disturbance of consciousness during transfer to the recovery room. Initial treatment with atropine produced rapid improvement in cardiovascular and cerebral function. A further hypotensive episode (without bradycardia) occurred approximately 1 h later but responded rapidly to methoxamine. The patient made a full recovery during an overnight stay on the High Dependency Unit. Possible mechanisms for this event are discussed, with the proposal that the concomitant administration of captopril and the relative unavailability of Angiotensin II may have significantly contributed to the problem.

The effect of the duration of stabilization of control responses on the onset and duration of clinical relaxation of suxamethonium 1 mg kg−1 and rocuronium 0.6 mg kg−1 were investigated in 90 patients. The control responses were allowed to stabilize for 1, 5, 10, 15 or 20 min prior to administration of rocuronium and for 1, 5, 10 or 15 min prior to suxamethonium. The mean onset time for rocuronium decreased from 150 to 46 s as the duration of stabilization increased from 1 to 20 min (P < 0.001) although the maximal effect was observed within the first 5 min. The average duration of clinical relaxation also increased from 25 to 40 min (P < 0.001). No effect was observed for either variable in the case of suxamethonium.

Replacement of the aortic valve exposes the left ventricle to myocardial ischaemia and imposes on it abrupt changes in loading conditions and geometry. We studied the immediate changes in the left ventricular function of patients undergoing aortic valve replacement by transoesophageal echocardiography. Patients with aortic regurgitation responded to surgery with a decrease in global systolic function associated with a fall in preload. Patients with aortic stenosis showed an impairment in myocardial contractility and ventricular filling, and their global systolic function did not improve despite the marked reduction in afterload. This can be a consequence of inadequate myocardial protection and intra-operative ischaemic injury of the hypertrophic myocardium. Information provided by transoesophageal echocardiography contributes to optimal and individualized management of the period immediately after aortic valve replacement.