Irrigation of the bladder after transurethral resection of the prostate is often distressing because of pain arising from detrusor muscle spasm. The effect of post-operative oral diazepam was compared with sacral epidural (caudal) block at the time of surgery, both treatments together and a control group, assessed by three-point rank scoring. Either treatment significantly reduced the incidence of pain reported by patients, P < 0.001. No patient experienced pain after both treatments.

Summary

Background and objective: The use of propofol compared with isoflurane is associated with improved patient comfort and decreased costs. However, as the cost saving, the quicker recovery time and patient comfort may not be evident if sevoflurane is substituted for isoflurane; these two anaesthetic agents were analysed in elderly patients.

Methods: In a prospective randomized study, 96 patients undergoing elective ophthalmic surgery received either total intravenous anaesthesia with propofol (Group P), propofol for induction and sevoflurane for maintenance (Group P/S) or sevoflurane for inhalation induction and maintenance (Group S). Analyses focussed on haemodynamics, the quality of recovery, and the costs for the anaesthetic and the entire procedure.

Results: Bradycardia or hypotension, mainly registered in Groups P and P/S, did not influence patients' recovery. In Group S, postoperative nausea and vomiting occurred frequently, and 50% of patients complained of discomfort during induction. In Group P/S, the costs for anaesthetics and total costs were lower than those in Groups P and S.

Conclusions: Propofol- and sevoflurane-based maintenance of anaesthesia were similar with regard to patient comfort and recovery in the elderly. Cost analysis revealed that it was less expensive to use propofol for induction and sevoflurane for maintenance than to use either propofol or sevoflurane as sole agents for anaesthesia.

In this study the effects of γ-hydroxybutyrate/fentanyl on cerebral blood flow velocity (CBFV) (as measured in the middle cerebral artery by transcranial Doppler ultrasonography) and on cerebrovascular carbon dioxide reactivity were investigated. Mean CBFV (̇Vmean) and haemodynamic responses were recorded in 12 non-neurosurgical patients before, during and after induction of general anaesthesia with γ-hydroxybutyrate (GHB) (20 min constant rate infusion of 100 mg kg−1). Two patients were excluded, one because of bradycardia and the other because of severe myoclonia. During the infusion of GHB, normocapnia was maintained by manually assisting ventilation as necessary. The infusion of GHB did not affect ̇Vmean [awake: 57±12 cm s−1 (mean±SD); 22.5 min: 62±15 cm s−1, NS difference] or mean arterial blood pressure (MAP) (awake: 97±12 mmHg; 22.5 min: 89±10 mmHg, NS). This suggests that cerebral blood flow velocity is unaltered by an anaesthetic dose of GHB. Twenty-five minutes after the start of GHB, fentanyl 3 μg kg−1 and vecuronium 0.1 mg kg−1 were given, the trachea was intubated and the lungs were mechanically ventilated to maintain end-tidal Pco2 of 4.6±0.4 kPa (30 min). At 30 min after the start of the GHB infusion, ̇Vmean and MAP decreased to 38±10 cm s−1 and 76±12 mmHg (both P<0.05 vs 22.5 min) respectively. After adjusting the ventilation to achieve hypocapnia (40 min: end-tidal Pco2 3.5±0.2 mmHg), ̇Vmean decreased to 29±7 cm s−1, while MAP did not change. This allowed the relative vasoreactivity (percentage change in ̇Vmean/0.133 kPa change in the end-tidal Pco2 from normocapnia to hypocapnia) to be estimated as 2.7±1.6% 0.133 kPa−1. This suggests that cerebrovascular response to CO2 during γ-hydroxybutyrate/fentanyl anaesthesia is maintained.

Summary

Background and objective: This prospective, double-blind, randomized, placebo-controlled study compares the effects of ephedrine and ketamine on injection pain, and hypotension from propofol.

Methods: After obtaining the approval of the Ethics Commitee, 75 patients (ASA I–II) scheduled for elective operations with general anaesthesia were divided into three groups. Saline 2 mL (Group S, n = 25), ketamine 0.5 mg kg−1 (Group K, n = 25) or ephedrine 70 μg kg−1 (Group E, n = 25) were administered over 5 s after tourniquet application. After releasing the tourniquet, propofol 2 mg kg−1 was injected in 30 s. Pain was evaluated on a numerical scale (0–10) where 0 represented no pain and 10 the most severe pain possible. Systolic, diastolic blood pressures and heart rates were recorded preoperatively, 1 min after propofol injection, before intubation and 1, 2 and 3 min after intubation in all patients.

Results: The incidences of pain in Groups S, E and K were similar (84%, 80% and 72%, respectively). The mean pain score in Group K (2.1, SD 3.1) was significantly lower than those of Groups S and E (4.9, SD 2.6 and 4.6, SD 3.3, respectively) (P < 0.05). The systolic and diastolic blood pressure values in Group K (120 ± 27 mmHg) and Group E (123 ± 21 mmHg) before intubation were significantly higher than that of Group S (104 ± 25 mmHg) (P < 0.05). There was no significant difference between the mean heart rate values of the groups.

Conclusions: Low dose ketamine or ephedrine pretreatment may prevent hypotension due to propofol induction. Despite the reduction in injection pain intensity after ketamine, the study drugs were found to be ineffective in lowering the injection pain incidence.

The management of surgical embolization of a post-traumatic carotid-cavernous fistula is reported in this study. The procedure was successfully performed with the aid of a fibreoptic intravascular catheter, which was monitoring continuously the changes of the jugular venous oxygen saturation. Jugular venous oxygen saturation monitoring effectively confirmed the success of embolization without the need for intraoperative angiography, by manifesting an abrupt return of oxygen saturation from arterial to normal venous values immediately after embolization.

Familial amyloid polyneuropathy (FAP) type I is a rare disease characterized by sensorimotor polyneuropathy, and autonomic nervous system and cardiac conduction system dysfunction. Severe bradyarrhythmia and hypotension may occur during anaesthesia and surgery in patients with the FAP type I. Only one report has been published of a patient with FAP type I who was managed with epidural anaesthesia. The present authors report a 38-year-old Japanese man with a permanent pacemaker because of advanced FAP type I who underwent rotation flap of the gluteus maximus muscle to cover a trophic ulcer in the sacral region under lumbar epidural anaesthesia. Ten millilitres of adrenaline (1:200 000) was injected around the ulcer prior to surgical manipulation. Neither bradycardia nor hypotension developed during the procedures. The haemodynamic changes under lumbar epidural anaesthesia in FAP type I are discussed.

Summary

Background and objective: Endogenous catecholamines are released in brain-dead organ donors following painful stimulation during retrieval surgery, and might be harmful to harvested organs. Our hypothesis was that inhibition of pain by fentanyl would inhibit such catecholamine release.

Methods: We tested 17 brain-dead organ donors in a randomized, placebo-controlled, double-blinded study. Blood samples for determination of epinephrine and norepinephrine concentrations were obtained before and 10 min after in take of either fentanyl 7 μg kg−1 or an equivalent volume of placebo. Further points of measurement were taken after skin incision and sternotomy. Mean arterial pressure and heart rate at these points were recorded.

Results: Catecholamine concentrations rose following painful stimuli. No differences in haemodynamics, between the fentanyl and the placebo group were detectable. Epinephrine concentrations, but not those of norepinephrine, were higher in the fentanyl group, reaching significance following sternotomy.

Conclusion: We conclude that the use of fentanyl (7 μg kg−1) was not effective in suppressing the catecholamine release, following painful surgical stimulation in brain-dead organ donors.

Summary

Background and objective: Epidural anaesthesia is the preferred technique of anaesthesia for Caesarean section in pre-eclampsia. Spinal anaesthesia is considered by some as a safe and effective alternative, which is especially useful in emergency situations. Combined spinal–epidural anaesthesia, using low doses of local anaesthetics with opioids, is effective and reduces the incidence of hypotension in normal pregnancy. We performed a retrospective chart analysis to evaluate the effects of combined spinal–epidural anaesthesia on maternal haemodynamics and fetal outcome compared to conventional epidural anaesthesia.

Methods: A retrospective anaesthesia chart analysis of all pre-eclamptic patients who underwent Caesarean section over a 4 yr period was performed. Patient characteristic, obstetric, haemodynamic, fetal and neonatal data were gathered and analysed according to the anaesthetic technique used.

Results: Seventy-seven pre-eclamptic parturients undergoing Caesarean section were identified (26 women were severely pre-eclamptic and 51 demonstrated mild pre-eclampsia). Epidural anaesthesia was performed in 62 patients and combined spinal–epidural anaesthesia was performed in 15. No differences in patient characteristic and obstetric data were noted. Highest mean arterial pressure prior to anaesthesia was comparable between the groups (epidural: 106 ± 12 vs. combined spinal–epidural anaesthesia: 109 ± 18 mmHg) as well as the lowest recorded mean arterial pressure following anaesthesia (epidural: 93 ± 13 vs. combined spinal–epidural anaesthesia: 98 ± 17 mmHg). In the combined spinal–epidural anaesthesia group more ephedrine was used compared to the epidural group (14.6 ± 4.4 vs. 3.6 ± 4.6 mg, P<0.05). However, more lactated Ringer's was used in the epidural group. Umbilical artery pH was lower in the epidural group (7.26 ± 0.01 vs. 7.29 ± 0.02, P<0.05). Similar results were noted in 26 severely pre-eclamptic patients. Seven women underwent combined spinal– epidural anaesthesia and 19 underwent epidural anaesthesia in the severely pre-eclamptic group. Also more ephedrine was used in the combined spinal–epidural anaesthesia group. A tendency towards a lower umbilical artery pH was observed in the epidural group but this difference did not reach statistical significance.

Conclusions: Combined spinal–epidural anaesthesia appears to be safe as anaesthetic technique for pre-eclampsia and severe pre-eclampsia. However, it is important to consider the retrospective design of the study and the large number of epidural anaesthetics performed.

Background and objective Polymorphonuclear leucocytes make a decisive contribution to defence against bacterial infections. In particular, the effects of anaesthetics on non-oxidative bactericidal mechanisms have previously only been superficially examined. Although the influence of anaesthetic agents on oxi-dative bactericidal activity has been thoroughly examined, our study concentrated on the effect on non-oxidative processes, which appears to have been a neglected field of research.

Methods The effects of methohexital, etomidate, ketamine, fentanyl and morphine on the activity of lysozyme and β-glucuronidase released from polymorphonuclear leucocytes have been studied in vitro. The activity of lysozyme was determined by recording the changes in the turbidity of a suspension of micro-coccus lysodeicticus caused by the enzymatic action of lysozyme. β-glucuronidase activity was photometrically measured by the enzymatic cleavage of phe-nolphthalein glucuronic acid.

Results High concentrations of methohexital inhibited lysozyme activity; however, etomidate and morphine caused an increase of β-glucuronidase activity in therapeutic plasma concentrations. While there was no effect of etomidate on lysozyme activity, all concentrations tested significantly stimulated β-glucuronidase activity. This result was unexpected because intravenous anaesthetics have previously shown a tendency to suppress polymorphonuclear leucocyte functions. Whereas the inhibition of lysozyme activity by the high concentration of methohexital was no surprise, the increase of β-glucuronidase activity caused by etomidate, ketamine, fentanyl and morphine was quite unexpected.

Conclusions At present, the underlying mechanism for the increase of β-glucuronidase activity caused by etomidate, ketamine, fentanyl and morphine is unknown. The fact that there was no influence of these agents on lysozyme activity possibly suggests that the anaesthetic agents have different effects on azurophilic and specific granules. Since in vitro investigations have their limitations, it is too early to draw practical consequences from our study. Moreover, at present it is unclear whether an increase of β-glucuronidase activity in vivo is an advantage or not. In any case, we think it advisable to perform further investigations on the influence of anaesthetic agents on oxygen-independent bactericidal mechanisms.