Summary

Background and objectives: Autonomic circulatory regulation and airway anatomy in children are significantly different from those in adults. There is no available published data to compare whether there is a clinically relevant difference in the haemodynamic responses to fibreoptic orotracheal intubation (FOI) under the same conditions between children and adults. In this randomized clinical study, we compared the blood pressure (BP) and heart rate (HR) changes during FOI in 40 children aged 3.5–9 yr and 40 adults aged 21–57 yr, ASA 1 scheduled for elective plastic surgery under general anaesthesia requiring orotracheal intubation. Methods: Anaesthesia was induced with intravenous (i.v.) injection of fentanyl and propofol, and face mask inhalation of isoflurane before FOI. Noninvasive BP and HR were recorded before induction (baseline values), after induction (postinduction values), at intubation and for 5 min after intubation at 1-min intervals. The percentage changes of BP and HR at each time point were calculated. Results: In children and adults, HR at intubation and 1–3 min after intubation were significantly higher than baseline and postinduction values. In adults, BP at intubation increased significantly compared to the postinduction values but did not exceed baseline values. In children, BP at intubation and 1 min after intubation were significantly higher than postinduction and baseline values. As compared to adults, FOI caused a more significant pressor response in children. The percentage changes of BP at intubation and 1 min after intubation were larger in children than in adults. However, there was no significant difference in the percentage change of HR during the observation between children and adults. Conclusions: Under general anaesthesia, FOI might cause a more significant pressor response in children than in adults.

Anaesthetic agents for day-case surgery ideally should have a short duration of action. This study was designed to compare the efficacy and safety of mivacurium and vecuronium for healthy adults undergoing dental day-case surgery. Thirty fit healthy adult patients (ASA I or II) randomly received either mivacurium 0.15 mg kg−1 (n = 15) or vecuronium 0.1 mg kg−1 (n = 15). Anaesthesia included propofol, fentanyl, nitrous oxide and isoflurane. Maximum depression of T1 was greater in the vecuronium group (99.8%) than in the mivacurium group (98.3%). There was no difference between grade of intubation at 2 min between the two groups, although patients receiving vecuronium had a more profound block at the time of intubation than those who received mivacurium (89.2% vs. 78.9%). Recovery to 10% T1 was faster in the mivacurium group (11.2 min vs. 33.1 min). All patients in the vecuronium group received neostigmine at the termination of surgery. The neostigmine evoked recovery index in the vecuronium group (4.39 min) was less than the spontaneous recovery index in the mivacurium group (6.78 min). One patient in the mivacurium group had a low plasma cholinesterase concentration (0.43 ku L−1); recovery times however, fell within the 95% confidence intervals (CI) for the group. There was no correlation between cholinesterase levels and recovery time. Mivacurium may be the more appropriate agent for dental day-case surgery because it has a shorter duration of action and does not generally require antagonism with an anticholinesterase.

Background and objective: The effects of clonidine and dopamine, both alone and together, on gastric tone were studied using an electronic barostat. This enabled volume changes to be measured in an intragastric bag with constant preset pressure.

Methods: Nine healthy male volunteers were each studied on two occasions in a randomized order. During each study period, a continuous infusion of dopamine was given, starting with a dose of 2.5 μg kg−1 min−1 and then increasing at 15-min intervals to 5.0 and 7.5 μg kg−1min 2 1. Clonidine 150 μg intravenously was given on one occasion during the infusion of dopamine (7.5 μg kg−1min−1) and on the other occasion 15 min before the dopamine infusion started.

Results: During dopamine infusion, the intragastric bag volume increased (gastric tone therefore decreasing) in a dose-related manner (total increase 290 6 114 mL). Clonidine given either during or before dopamine infusion did not influence the bag volume. When the dopamine infusion started 15 min after clonidine, the bag volume did not change until the infusion of dopamine reached 7.5 μg kg−1min−1(total increase 205 6 156 mL).

Conclusions: Dopamine reduced gastric tone in a dose-related manner, and clonidine did not influence gastric tone per se. If clonidine is given before dopamine, the effects of dopamine are reduced.

Summary

Reporting systems are becoming more widespread in healthcare. Since they may become mandatory under the pressure of insurance companies and administrative organizations, it is important to begin to go beyond a case-by-case approach and to move to a system where there is a general reflection on the best conditions of development and setting up of such systems in medicine. In this paper, we review existing reporting systems, break down their components, examine how they are constructed and propose some ideas on how to articulate them in a dynamic process in order to improve the validity of the tool as mediator of safety, quality and well-being at work.

Background and objective: The aim was to examine the immediate effects of short-term anaesthesia on the different components of psychomotor performance of the upper extremity and cognitive functions, and to find out if there were any differences in the sensitivities of the different tests. The measured psychomotor aspects were simple reaction time, choice reaction time, speed of movement, index finger-tapping speed, co-ordination, visual spatial memory capacity, digit-symbol substitution and the Maddox Wing test.

Methods: The subjects were 30 female patients aged 24–50 yr who had been through a minor gynaecological operation. Anaesthesia had been induced with propofol and alfentanil. The measurements were mainly made with the HPM/BEP system, and the tests were performed 1 h before the anaesthesia and immediately after the wake-up.

Results: Short-term anaesthesia prolonged the simple reaction time by 7% and the choice reaction times by 25% (one-choice) and 7% (two-choice) and decreased the speed of movement by 10% (one-choice) and 19% (two-choice), index finger-tapping speed by 7% and co-ordination by 7%. In addition, visual spatial memory capacity decreased by 21%, digit-symbol substitution increased by 5% and the Maddox Wing test increased by 68%.

Conclusions: Based on the results, it seems that short-term anaesthesia reduces both signal processing at the central level, and motor control and co-ordination of movements at the peripheral level, and has a decreasing effect on motor performance in the above-mentioned aspects measured immediately after wake-up.

Information about physician anaesthesiologist manpower in the countries of the European Union was collected from questionnaires sent to the delegates representing their respective countries on the European Board of Anaesthesiology.

In the countries of the European Union and Switzerland and Norway 40 259 specialist anaesthesiologists are recorded. The number of anaesthesiologists in relation to population varies between as little as 4.4 and 4.6 (Ireland and UK) and as many as 15.6 (Italy), with a mean of 10.8/100 000 inhabitants. There are 11 610 physicians recorded in training in anaesthesiology.

The ratio of trainees to specialists in the European Union countries was 28.8/100, varying from as low as 6.5 in France, to as high as 96.7 and 98/100 in Ireland and the UK respectively.

These figures indicate a wide difference in the numbers of specialists and trainees between the European countries studied. However, the overall mean figure is close to that reported in the USA (9.2/100 000).

Summary

Background and objective: This study was designed to compare the haemodynamic, electrophysiological and pharmacodynamic effects of three selective inhibitors of the different isoenzyme forms of phosphodiesterase (PDE) on ischaemia-induced dysrhythmias in the anaesthetized rat. The drugs used were pimobendan, a selective PDE III inhibitor, rolipram, a selective PDE IV inhibitor, and zaprinast, a selective PDE V inhibitor.

Methods: The coronary artery was occluded 15 min after commencing drug administration, and myocardial ischaemia was maintained for 30 min during which the heart rate and mean arterial pressure were recorded. cAMP and cGMP were determined by radioimmunoassay.

Results: Pretreatment with rolipram decreased the duration of ventricular tachycardia without any change in the incidences of dysrhythmias or the mortality rate. This drug did not modify ventricular content of adenosine 3′,5′-cyclic monophosphate (cAMP) or guanosine 3′,5′-cyclic monophosphate (cGMP). Pimobendan (1 mg kg−1 + 0.1 mg kg−1 min) decreased the duration of ventricular tachycardia. This dose of pimobendan and zaprinast (1 mg kg−1 + 0.1 mg kg−1 min−1) increased the incidence rate of ventricular fibrillation following coronary artery ligation and the mortality rate. Moreover, both drugs increased cGMP in the ventricle.

Conclusions: The results demonstrated that pimobendan and zaprinast increased the incidence of dysrhythmias and the mortality rate, which was accompanied by an increase in the ventricular content of cGMP. Rolipram decreased the duration of ventricular tachycardia without a change in the cyclic nucleotide content or in the mortality rate.

Megaoesophagus resulting from achalasia is a rare but serious cause of airway obstruction. The exact aetiology remains unclear. Although 29 cases have previously been reported, the potential need for urgent treatment has not been suf®ciently emphasized. Some forms of treatment with drugs or decompression with a ®ne tube have been advocated but emergency tracheal intubation may become necessary. A 90-year-old lady had a bolus of food lodged in her oesophagus but with no respiratory symptoms.

A 90-year-old lady had a bolus of food lodged in her oesophagus but with no respiratory symptoms. The bolus was removed under anaesthesia. Six weeks later she suffered similar symptoms after eating but developed severe airway obstruction over 10 min. Emergency intubation of the trachea was necessary before removing the food bolus under general anaesthesia. This case demonstrates the urgency with which these patients may need to be treated. The condition can rapidly worsen due to swallowing of air and saliva.

Sufentanil or a sufentanil-clonidine combination was evaluated to determine whether the basal rate in patient-controlled epidural analgesia (PCEA) might affect the daily consumption, quality of analgesia or incidence of side effects. Following Caesarean section delivery, 60 patients were randomly assigned to receive one of the four following PCA regimens (15 patients per group) for the relief of post-operative pain by the epidural route: sufentanil 2μg mL−1 in 0.9% NaCl, demand dose 5μg i.e. 2.5mL, (group S+ with, group S without an infusion at 2.5mL hr−1) or sufentanil 2μg mL−1 + clonidine 3μg mL−1, demand dose 5μg sufentanil + 7.5μg clonidine i.e. 2.5mL (group SC+ with and SC without an infusion of 2.5ml hr−1). The other PCA settings (Bard I PCA pump) were a lock out interval of 10 min and a 1h limit of 20μg sufentanil and 30μg clonidine i.e. 10mL. The parameters measured were the analgesic drug consumption and number of dose demands during the first 24h, pain scores at 6h intervals, side effects and quality of sleep. The concurrent infusion increased the dose requirements regardless of the content of the syringe. Consumption of sufentanil was the highest in those patients receiving the plain solution with a basal infusion. Clonidine addition reduced the dose requirements but only significantly in those receiving the background infusion. Patients treated with the mixture tended to reach lower pain scores than those receiving sufentanil only without basal rate. Patients receiving the mixture with basal rate requested significantly fewer additional demands compared with the three other groups, but this did not influence the quality of sleep. Since side effects were more frequently registered in the patients in this group, it was concluded that the optimum regimen was the sufentanil-clonidine combination but with deletion of the basal rate.

Sixty patients presenting for in-patient gynaecological laparoscopic surgery were randomly allocated to receive either diclofenac 75 mg (n = 20), ketorolac 30 mg (n = 20) or piroxicam 20 mg (n = 20) as an intramuscular (i.m.) injection immediately after induction of anaesthesia. Post-operative Visual Analogue Scores at rest, over the first 24 h after surgery, using a 10 cm scale, ranged from 3.2–0.5 in the diclofenac group, 2.7–0.85 in the ketorolac group and 2.8–0.5 in the piroxicam group. The scores did not differ significantly between the three groups (P > 0.05). Mean time (SD) to first analgesia was 27 (94) min in the piroxicam group, 16 (30) min in the diclofenac group and 62 (120) min in the piroxicam group. Six out of 20 patients in the diclofenac group required further analgesia compared with nine out of 20 in the other two drug groups, this was not significant. There were no reports of increased bleeding, bronchoconstriction, bleeding from the upper gastrointestinal tract, renal impairment or pain from the intramuscular (i.m.) injection site in any of the groups. The administration of a non-steroidal anti-inflammatory drug to patients presenting for laparoscopic surgery reduces post-operative pain and analgesic requirements, and piroxicam 20 mg provides a suitable alternative to 75 mg diclofenac and 20 mg ketorolac.

A 72-year-old woman had a minitracheostomy inserted for sputum retention. This was undertaken by a relatively junior resident who opted to use an early model minitracheostomy kit Minitrach II. The following day the patients condition deteriorated and intubation was warranted, at which time it was apparent to senior staff that the minitracheostomy had been malpositioned. Ten days later, formal tracheostomy was performed under general anaesthesia. After incision,an abscess in the thyroid gland was found. Histology subsequently revealed a Hurthle cell tumour of the thyroid. Thyroid abscess is exceedingly rare. It typically occurs in abnormal thyroid tissue and with a focus on infection. The combination of Hurthle cell adenoma and a foreign body (the minitracheostomy) was evidently causative in this instance. This complication of minitracheostomy insertion has not to our knowledge, previously been reported.