Summary

Background and objective: The ease of endotracheal intubation has been recently shown to affect the incidence of laryngeal injury. There remains controversy as to whether or not a muscle relaxant is routinely required for tracheal intubation. This study examined conditions of intubation in our routine practice, which employs a relaxant-sparing approach. Methods: All adult patients scheduled for surgery with general anaesthesia were prospectively included. A muscle relaxant was used to facilitate intubation when it was required for the surgical procedure and/or otherwise regarded as necessary by the anaesthesiologist. In the remaining patients, a relaxant-free intubation was performed. Intubating conditions were evaluated in all the patients as well as the post-intubation laryngeal symptoms. Results: Between March and July 2003, 612 patients were consecutively included. A muscle relaxant was used in 32% of patients and no relaxant in the remaining patients (68%). Clinically acceptable intubating scores were observed in 98.4% overall with no significant difference between the two groups. Excellent conditions occurred more frequently in the relaxant group as compared to the relaxant-free group, 87% vs. 72%, P = 0.005. Laryngeal symptoms occurred in 184 (33%) patients with no difference between the two groups. Conclusions: Our relaxant-sparing approach did not increase the incidence of poor conditions of intubation nor laryngeal symptoms. However, excellent conditions occurred more frequently in the relaxant group. A more flexible approach to the issue of the need for neuromuscular blockade prior to intubation is proposed.

Profound and complex coagulation disorders are encountered during liver transplantation. They include preoperative coagulation disorders related to the liver disease and haemostatic changes related to the procedure itself. They commonly lead to increased intraoperative bleeding, especially due to increased fibrinolysis, the contribution of which can be demonstrated by the relative efficacy of antifibri-nolytics. Given the multifactorial nature of bleeding in liver transplantation, preoperative coagulation tests cannot predict blood loss even if some statistical relationship is occasionally found.Preoperative correction of coagulation defects has not been shown to be effective in reducing intraoperative bleeding. Throughout the procedure, a rapid and sensitive method for monitoring coagulation is necessary in order to guide the rational use of blood components and pharmacological agents. The usefulness of such a method to assist management of blood loss or blood component requirements is poorly documented and controversial.

Epidural analgesia is the most effective and innocuous technique for obstetrics. Pain relief is its main indication but maternal diseases that might be decompensated by labour and delivery are also accepted indications. Low doses of long-acting local anaesthetics alone or in combination with low doses of fentanyl or sufentanil provide good quality analgesia and are safe for mother and fetus. Test doses in parturients lack sufficient specificity and sensitivity for detecting inadvertent intravascular injection, and subarachnoid migration of the catheter is possible at any time during the procedure. Therefore, every injection must be considered as a test dose and only fractionated injections must be made. Epidural block to T10 is needed for labour and to level T4 for Caesarean section. Maintenance of the block with a continuous infusion, or patient-controlled epidural analgesia with a background continuous infusion, provides more stable analgesia than by intermittent injection. Technical difficulties, dural tap, bloody tap, hypotension and insufficient block are most frequent complications of epidural block in obstetrics. Excessive motor block prolongs the second stage of labour and increases the frequency for instrumental delivery and is therefore considered a complication

Appropriate airway management is an essential part of the anaethetist's role. Difficult intubation, which can now be quantified using the ‘Intubation Difficulty Scale’, should be anticipated whenever possible. A strategy needs to be developed in order to anticipate problems. The first part of this paper reviews the different factors that contribute to make intubation and/or ventilation difficult. Problems with intubation (or ventilation of the lungs) can be caused by abnormal laryngeal structures (e.g. tumour, stenosis), or by difficulty in seeing the glottis. The clinical history will usually help identify the former problem, while physical examination of the airway is required to reveal either disproportion between the various structures of the airway (e.g. tongue, larynx), and/or difficulties in aligning the oral, pharyngeal, and laryngeal axes. The different techniques used to diagnose these problems are described. The second part of this paper summarizes the algorithms used by the anaesthetist when management of the airway is found difficult. Three situations are considered: (a) anticipated difficult intubation, for which awake fibreoptic intubation would appear to be the technique of choice in the majority of cases, (b) unforeseen difficult intubation in a patient whose lungs can be ventilated; here, various techniques for control of the airway will be briefly described, and (c) both tracheal intubation and lung ventilation are impossible; this is a life-threatening emergency, for which three solutions are proposed. These include use of the laryngeal mask airway, the Combi-tube®, or transtracheal ventilation. These situations will be analysed with the aim of proposing management strategies that always guarantee the safety of the patient.

There is an increasing body of evidence that volatile anaesthetics protect myocardium against ischaemic insult by a mechanism termed ‘anaesthetic preconditioning’. Anaesthetic preconditioning and ischaemic preconditioning share several common mechanisms of action. Since ischaemic preconditioning has been demonstrated in organs other than the heart, anaesthetic preconditioning might also apply in these organs and have significant clinical applications in surgical procedures carrying a high risk of ischaemia–reperfusion injury. After a brief review on myocardial preconditioning, experimental and clinical data on preconditioning in non-cardiac tissues will be presented. Potential benefits of anaesthetic preconditioning during non-cardiac surgery will be addressed.

Summary

Background and objective: Cardiopulmonary bypass is known to induce postoperative coagulopathy including fibrinolysis. We have evaluated the effect of the topical use of tranexamic acid in the pericardial cavity on postoperative bleeding following open heart surgery. Methods: One hundred patients, scheduled for elective open heart surgery, were included in this double-blind, prospective, randomized, controlled study. They were allocated to a treatment group (Group I), or placebo group (Group II). Patients with coagulopathies, renal failure, re-do surgery, or recent anti-platelet treatment were excluded. In Group I, tranexamic acid (2 g in 100 mL of saline solution) was poured into the pericardial cavity before sternal closure. Placebo patients received 100 mL of saline. Postoperative blood loss, need for transfusion of blood products and the rate of re-sternotomy for bleeding were documented. Results: During the first postoperative 24 h, cumulative blood loss was significantly higher in Group II compared to Group I (1208 ± 121 mL vs. 733 ± 93 mL, respectively) (P < 0.001). More blood transfusions were administered to Group II patients (4.54 ± 1.4 units) as compared to Group I patients (2.64 ± 1.5 units) (P < 0.01). Conclusion: Topical application of tranexamic acid in patients undergoing primary open heart surgery led to a significant reduction of both postoperative mediastinal bleeding, and rate of re-exploration for haemostasis.

Summary

Background and objective: We have compared the effects of gabapentin on arterial pressure and heart rate at induction of anaesthesia and tracheal intubation in a randomized double-blind study. Methods: Ninety normotensive patients (ASA I) undergoing elective surgery were divided into three groups of 30 patients each. Patients received oral placebo (Group I), 400 mg of gabapentin (Group II) or 800 mg of gabapentin (Group III) 1 h prior to surgery in the operating theatre. After induction of anaesthesia heart rate and mean arterial pressure were recorded at baseline 1, 3, 5, 10 and 15 min after intubation. Results: Patients receiving placebo and 400 mg gabapentin showed a significant increase in blood pressure and heart rate associated with tracheal intubation compared to baseline levels and Group III. There was significant decrease in heart rate and arterial pressure in Group III after intubation 1, 3, 5 and 10 min (P < 0.001, P < 0.001, P < 0.05 and P < 0.05, respectively) compared to Groups I and II. Conclusion: Given 1 h before operation gabapentin 800 mg blunted the arterial pressure and heart rate increase in first 10 min due to endotracheal intubation. Oral administration of gabapentin 800 mg before induction of anaesthesia is a simple and practical method for attenuating pressor response to laryngoscopy and tracheal intubation after standard elective induction.

Background and objective Intravenous morphine titration is used to obtain postoperative pain relief, but few studies have assessed the appropriate regimen. In a quality programme, we performed a prospective non-randomized study of morphine titration in a postanaesthesia care unit (PACU).

Methods Four regimens of morphine titration were studied: every 10 (group 1, n = 400) or 5min (group 2, n = 400) with a maximum of five intravenous boluses; every 5min, without any limitation in the number of boluses (groups 3 and 4, n = 400 each); in groups 1, 2, and 3, subcutaneous morphine was administered 4 h after titration. In group 4, administration of subcutaneous morphine was allowed only 2h after titration. A visual analogue pain scale (VAPS) > 30 mm was required to administer morphine and pain relief was defined as a VAPS ≤ 30 mm.

Results After morphine titration, VAPS was lower and the number of patients with pain relief was greater in patients from groups 3 and 4. Patients from group 4 had the lowest VAPS (26±17mm) and the highest percentage of pain relief (73%) at the end of the PACU period. The number of sedated patients increased in groups 3 (62%) and 4 (61%) compared with group 1 (27%). No significant differences in morphine-related adverse effects were observed.

Conclusion Intravenous morphine titration every 5min with an unlimited number of boluses and early subcutaneous administration provided the best analgesic regimen.

Data on the cerebrovascular effects of catecholamines after head injury are difficult both to interpret and to compare. Diverse parameters with regard to brain trauma animal models, methods of determining the effects on the cerebral blood flow and metabolism and choice of end-points have been used. Many studies investigate the cerebrovascular effects of catecholamines over a range of cerebral perfusion pressures above the range recommended by current guidelines. The relationship between patient outcome and the use of a specific substance to improve cerebral perfusion has not been investigated. Dopamine, norepinephrine and phenylephrine all seem to increase cerebral blood flow in various animal models and in patients. The data suggest that norepinephrine may be the most predictable. It is associated with an improved restoration of global and regional oxygenation when compared to dopamine. Dopamine has been associated with an increase in brain oedema. There is further evidence that dopamine has many disadvantages in critically ill patients due to its ability to suppress circulating concentrations of most anterior pituitary-dependent hormones. Both aspects would further discourage its use. Data on phenylephrine are scarce. It has been associated with increased intracranial pressure and a failure to improve cerebral oxygenation despite markedly improved cerebral perfusion pressure. For all other catecholamines and related substances there are insufficient data on the cerebrovascular effects after head injury. This suggests that norepinephrine may be the catecholamine that is the most suitable substance to maintain or restore adequate cerebral perfusion. The data, however, are insufficient to formulate a guideline.

Summary

Background and objective: The perception of a looming manpower shortage led the French College of Anaesthesiologists (CFAR) and the French Society of Anaesthesia and Intensive Care (SFAR), with assistance from the National Institute for Demographic Studies (INED), to conduct a national survey of French anaesthesiologists in order to determine precise physician characteristics data, analyse professional practices and project future service provision.

Methods: The survey was based on self-administered individual questionnaires, approved by the National Committee on Informatics and Freedom (CNIL). The survey was carried out at the end of 1998 among 1484 hospitals (590 public and 894 private), under the supervision of local referees and regional co-ordinators.

Results: Of 9741 anaesthesiologists' posts, 5694 (58%) are in public hospitals, 3569 (37%) in private practice and 478 (5%) in private hospitals within the National Health Service, i.e. the participant au service public hospitalier (PSPH). Complex validation of the results was necessary to account for the missing responses and multiple sites of activity. The survey identified 8876 specialists practising anaesthesia and intensive care in France at the beginning of 1999, including 216 in French overseas territories. This figure is consistent with that published by the Medical Council (Ordre des Médecins) on 1 January 1999, identifying 8950 anaesthesiologists in France, including 234 in the overseas territories. Annual growth in the anaesthesiologist population has fallen from 9% pre-1989 to 0% in 1999. Male anaesthesiologists outnumber females (35.7%). The average age has risen from 42.8 yr in 1989 to 45.9 yr in 1999. The age distribution of anaesthesiologists has become bell shaped, reflecting reduced numbers of younger practitioners. There are currently 14.75 anaesthesiologists per 100 000 people (compared to 12.9 in 1989), a figure slightly above the European average, but there is considerable geographical inequality between the north and south of France, with increased concentrations in large cities that contain university hospitals.

Conclusions: Future service provision must take account of falling numbers of new anaesthesiologists and an increase in retirements, but must also include changes in working practices, such as the European Working Time Directive. If anaesthesia manpower shortages are to be avoided, there must be a restructuring of the workplace, a redefinition of tasks and improved management of working time.

Summary

Objective: To assess the ability of medical students to learn and retain skills of airway manipulation for insertion of the endotracheal tube, the laryngeal mask airway (Laryngeal Mask Company, Henley-on-Thames, UK) and the oesophageal–tracheal Combitube® (Kendall-Sheridan Catheter Corp., Argyle, NY, USA).

Methods: A 6-month prospective study was conducted among fifth-year medical students attending a 3-week clerkship in the Division of Anesthesiology and Critical Care Medicine in the Soroka Medical Center. All the students viewed a demonstration of insertion technique for the endotracheal tube, the laryngeal mask airway and the Combitube®, followed by formal teaching in a mannikin. At the end of the program, the insertion skills were demonstrated in the mannikin, the success rate on the first attempt was registered and the students were requested to assess (by questionnaire) their ability to execute airway manipulation (phase 1). Six months later, the students were requested to repeat the insertion technique, and a similar re-evaluation applied (phase 2).

Results: The success rate, during the first phase, at first attempts was 100% for the laryngeal mask airway and the Combitube®, compared to 57.4% for the endotracheal tube (P < 0.02), and 92.6%, 96.2% and 62.9% (P < 0.02) respectively for the second phase of the study.

Conclusion: Learning and retention skills of medical students, in a mannikin, are more accentuated with the laryngeal mask airway and the Combitube® than seen with an endotracheal tube.

Patient attitudes to medical information are changing. We audited patient attitudes to an information leaflet provided at the preadmission clinic as part of standard day-case protocol. The booklet is a simplified version of the booklet Anaesthesia and Anaesthetists – Information for Patients and Relatives published in London, UK, by the Association of Anaesthetists of Great Britain & Ireland. One hundred and three patients were surveyed before surgery over a 2-month period using an anonymous questionnaire. Of the 96% of patients who read the booklet provided, 99% found it helpful to some degree. Thirty-five per cent of patients found it worried them. Thirty-two per cent discussed the information with others but only 3% discussed the information provided with the anaesthetist. Although patients like to receive information about the process of anaesthesia, we must be careful that by providing it in an inappropriate form, e.g. as a leaflet, we do not increase their preoperative anxiety.

Summary

Background and objective: Unplanned hospital admission is a measure of quality of care in the setting of day-case surgery. We set out to identify the incidence and causes of unplanned hospital admission in a paediatric day-case unit.

Methods: A retrospective survey to determine the incidence and causes of unplanned hospital admissions in children undergoing day-case surgery. The survey covered the period from January 1996 until December 1999 inclusive in a university affiliated children’s hospital. This hospital is the second largest paediatric referral centre in Ireland with total admissions across all specialities during the study period of 42 738.

Results: During the study period 10 772 children underwent day-case surgery, of whom 242 (2.2%) experienced unplanned hospital admission. The reasons for admission were surgical 146 (54%), anaesthetic 44 (16%), social 38 (14%), medical 31 (11%) and unclassified 10 (4%). Pain, surgical complications and/or further management, admission for observation, extensive surgery and oozing were the commonest surgical reasons. Postoperative nausea and vomiting, anaesthetic-related complication and somnolence were the commonest anaesthetic causes responsible for admission. Surgery performed after 15:00 h was an important factor associated with admission for social reasons. Orthopaedic surgery accounted for the largest absolute number of unplanned admissions with 61 (25%), followed by urology with 46 (19%) and general surgery with 46 (19%). However, measured as percentage of caseload, urology had the highest proportion of unplanned hospital admissions.

Conclusion: This study demonstrated that the incidence and causes of unplanned hospital admission following day-case surgery in children are similar to those for adults.