This study compares prospectively the cardiovascular and catecholamine responses to central venous and pulmonary artery catheterization before and after induction of general anaesthesia. Twenty patients for elective coronary artery surgery were randomized into two groups. One group had central venous and pulmonary artery catheterization performed awake using local anaesthesia. The other group had these catheters inserted following induction of general anesthaesia. In all patients heart rate, arterial blood pressure, ST segment analysis and epinephrine and norepinephrine levels were measured prior to central venous cannulation and at 2-min intervals until placement of the lines was achieved. There were no statistically significant changes in any cardiovascular or catecholamine variable with time compared with the base–line measurements. There were no statistically significant differences in plasma catecholamine levels between the awake and the anaesthetized groups.

Amide local anaesthetics inhibit platelet function. We hypothesized that residual anaesthetic in the epidural space could decrease efficacy of an epidural blood patch in preventing postdural puncture headache. Levobupivacaine has recently been approved for epidural anaesthesia. Its effects on coagulation have not previously been studied. The aim of this study was to determine the effects of levobupivacaine on clotting using thromboelastography. Ten ASA Class I volunteers were studied. Venous blood samples were analysed using a Haemoscope 2000D TEG analyser. Whole blood, a 50% saline control and two levobupivacaine solutions (2.5 mg mL−1 and 2.5 μg mL−1 in blood) were compared. The former reproduces that produced in the epidural space by blood (20 mL for an epidural blood patch) and levobupivacaine 0.5% (20 mL). The latter approximates plasma concentrations following epidural injection of levobupivacaine 0.5% (20 mL). P < 0.05 was considered significant. Maximum amplitude (MA), a measure of clot strength, is decreased by levobupivacaine 2.5 mg mL−1. Levobupivacaine 2.5 mg mL−1 decreases clot strength and may reduce efficacy of a prophylactic epidural blood patch.

Fifty children (2–9 years) scheduled for tonsillectomy were enrolled in a double-blind randomized prospective study to compare postoperative analgesia provided with propacetamol/paracetamol (acetaminophen) or tramadol. A standard anaesthetic technique was used; each patient received sufentanil 0.25 μg kg−1 intravenously followed with either i.v. propacetamol 30 mg kg−1 or tramadol 3 mg kg−1 before surgical incision. For postoperative analgesia, each child received either tramadol drops (2.5 mg kg−1) or paracetamol (acetaminophen) suppositories (15 mg kg−1), 6 and 12 h after surgery the first day and three times a day during postoperative days 2 and 3. This dosage of paracetamol is lower than the current recommended dosage, which is 40 mg kg−1 loading dose followed by 20 mg kg−1 8 h−1. Rescue medication consisted of i.v. diclofenac (1 mg kg−1) during the first six postoperative hours and oral ibuprofen (6–9 mg kg−1) afterwards. Postoperative pain scores (Children's Hospital of Eastern Ontario Pain Scale) in recovery, numerical pain scale in the ward and at home, and rescue analgesic use were significantly lower in the tramadol group. No serious adverse effects were observed.

The intraoperative effects of continuous spinal anaesthesia, and the efficacy of postoperative continuous spinal analgesia in 48 elderly high risk patients undergoing major abdominal, vascular or orthopaedic surgery is reported. Intraoperative anaesthetic technique proved to be safe and provided satisfactory results in the immediate postoperative period. Furthermore, the postoperative analgesic regimen which involved intrathecal fentanyl and bupivacaine, and intravenous tenoxicam, provided effective analgesia for all patients. The intrathecal analgesic regimen was administered continuously through a PCA pump which had the facility to provide bolus doses when requested in predetermined lockout intervals. The mean doses of fentanyl and bupivacaine infused intrathecally for the first 24 h postoperatively were 14.5±1.5 μg h−1 (mean±SD) and 0.72±0.08mg h−1 (mean±SD), respectively, while the requirements for analgesia decreased progressively over time but lasted for 118 h. The technique provided effective analgesia with low pain scores that was reflected by the ease in performing physical exercises and the pleasant co-operation with the physiotherapist. Only minor complications related to anaesthesia/analgesia were encountered.

Tracheostomy is necessary in intensive care unit (ICU) patients requiring prolonged mechanical ventilation. As an alternative to the standard surgical method, percutaneous techniques are available. Seventy-two patients were electively selected for percutaneous tracheostomy (PCT) in a nine-bed combined medical-surgical intensive care unit. PCT was performed at bedside with the Portex Percutaneous Tracheostomy Kit that uses the Griggs technique. The procedure time and early complications were recorded. The procedure was successful in all patients. The average duration of placement was 7.4 min. There were no tracheostomy-related deaths. Major bleeding occurred in three patients and required surgical intervention. In one patient, minor bleeding occurred at the stoma site that resolved with applied pressure. Wound infections were treated with local antiseptics in two patients. These findings suggest that PCT is a simple, quick and safe procedure.

A survey was constructed to ascertain the views of The Royal College of Anaesthetists tutors regarding the acceptability of inhalational induction with sevoflurane for emergency anaesthesia. A questionnaire was sent to all tutors asking them to indicate their preferred choice of anaesthetic technique, and whether they believed inhalation induction with sevoflurane to be acceptable, in each of four scenarios: acute epiglottis; bleeding after tonsillectomy; appendicitis; and laparotomy in the shocked patient. Two hundred and sixty-two (89%) completed questionnaires were received from 294 college tutors. We have shown that the majority of The Royal College of Anaesthetists tutors would use sevoflurane for patients with an acutely compromised airway. One in four college tutors would accept the use of sevoflurane for a shocked patient for laparotomy. Anaesthetists who manage critically ill patients with an inhalational induction should be reassured by the fact, that a significant proportion of their colleagues would find this technique acceptable.

In a randomized, prospective clinical study pain relief and pulmonary function were compared after upper abdominal surgery when thoracic epidural analgesia was instituted either before or after surgery. Twenty-six patients admitted for surgery to treat gastro-oesophageal reflux received thoracic epidural analgesia as an adjunct to general anaesthesia either before or after surgery. Twelve patients received epidural mepivacaine 20 mg mL−1 and morphine perioperatively. Another 14 patients received an epidural bolus of bupivacaine 2.5 mg mL−1 and morphine after skin closure. Bupivacaine 2.5 mg mL−1 with morphine was adminstered to all patients for three postoperative days. No intergroup differences were found regarding pain at rest and mobilization. The requirement for additional analgesics was similar in both groups as well as peak expiratory flow. Thoracic epidural analgesia that had already been induced before surgery, and was continued into the postoperative period, does not seem to add any advantage regarding pain relief and lung function compared with thoracic epidural analgesia instituted in the immediate postoperative period.

The effects of inhalational anaesthetic agents on renal sympathetic nerve activity (RSNA) were compared in anaesthetized rabbits. Concentrations of 6% desflurane, 1.2% isoflurane, and 2.4% enflurane increased mean RSNA up to 32, 36 and 44% while higher concentrations, of 12, 2.4 and 3.2% depressed it by 42, 83 and 5%, respectively. For halothane RSNA was unchanged up to 0.8% and decreased by 36% at 1.6% concentration. Nitrous oxide increased RSNA up to 28% at 50% concentration. Maximum reductions in mean arterial pressure (MAP) were 60% for both 2.4% isoflurane and 3.2% enflurane, 50% for 12% desflurane and 1.6% halothane, while 70% nitrous oxide increased MAP by 22%. In conclusion, unlike the entirely depressive effects of halothane, the effects of desflurane, isoflurane and enflurane were biphasic involving excitation at lower concentrations and depression of RSNA and a reduction in MAP at higher concentrations. Nitrous oxide caused increases in both RSNA and MAP.

This study investigated the changes in the hypnotic component of anaesthesia, estimated by the bispectral index of the electroencephalogram, during normothermic cardiopulmonary bypass. Twenty-six patients (20 men, 6 women), aged 61±11 years (Mean±SD) scheduled for cardiac surgery were premedicated with hydroxyzine and meperidine. Anaesthesia was induced and maintained with a computer-controlled continuous infusion (not adjusted for haemodilution) of sufentanil (effect site concentration 0.4–0.6 ng mL−1) and a manually adjusted continuous infusion of propofol (4.4±1.8 mg kg−1 h−1). Cardiopulmonary bypass was normothermic with moderate haemodilution. Bispectral index was measured with a referential montage before, 30 s, 1, and 3 min after cardiopulmonary bypass onset, before and after aortic cross-clamping, 30 min after cardiopulmonary bypass onset, before and after aorta cross-clamp release and before and after weaning from cardiopulmonary bypass. Bispectral index values were 48±8 before cardiopulmonary bypass onset, 50±10 before, and 48±8 after end of cardiopulmonary bypass (P=NS). No patient had increases in bispectral index values during cardiopulmonary bypass consistent with awakening. We conclude that with the anaesthetic regimen presented in this study bispectral index values do not change during normothermic cardiopulmonary bypass.

A case is presented of a neonate with Hirschsprung's disease, associated with congenital central hypoventilation syndrome. After an ileostomy (at 2 days) and a stoma revision (at 10 days), postoperative pain management was established by continuous intravenous infusion of morphine, which caused severe postoperative respiratory depression. At 6 weeks a reexploration and stoma revision was performed using postoperative epidural analgesia with bupivacaine. This caused no respiratory depression. A colectomy under epidural analgesia at 8 months was also uneventful. Respiratory difficulties in children with congenital central hypoventilation syndrome associated with Hirschsprung's disease are discussed in relation to the technique of choice for postoperative pain management.

A recent study in our department demonstrated that depressing the plunger of a 50-mL syringe was reliably and linearly related to the force applied between 20N and 50N. Using a 50-mL syringe we constructed a simple device to help train anaesthetic assistants to apply cricoid pressure correctly. We then tested anaesthetists, operating department practitioners (non-physicians) and nurses in our hospital to see if they could correctly apply forces of 20 and 40 N. All subjects were then trained using this apparatus and once confident were retested immediately afterwards, and again 1 week and 1 month later. The results show a wide variation in the force applied with only 30% of subjects applying appropriate force at 20N, and 40% at 40N. Training leads to a significant improvement in performance (P < 0.005 at 20N and P < 0.001 at 40N) which is maintained for 1 week for both 20N (P < 0.05) and 40N (P < 0.05) but not for 1 month. Therefore training should be practised on a weekly basis. This is an inexpensive and simple device that we believe to be useful in helping anaesthetic assistants to apply effective cricoid pressure.

We examined the relation between chronic glycaemic control (using glycosylated haemoglobin), haemodynamic autonomic function and rate of gastric emptying in 16 patients with type 1 diabetes mellitus. Gastric emptying was measured using a paracetamol absorption technique. Parameters of gastric emptying include area under the plasma paracetamol concentration time curve. Patients were classified as diabetic autonomic neuropathy positive or negative using five standardized haemodynamic reflex tests. Area under the plasma paracetamol concentration time curve in the neuropathy positive (10.36 (4.5) mmol−1 min) and negative (9.84 (3.0) mmol−1 min) groups were similar (P=0.42) using unpaired Student's t-tests. Glycosylated haemoglobin concentration and area under the plasma paracetamol concentration time curve (n=16) demonstrated a Pearson's correlation co-efficient of 0.24. Neither tests of haemodynamic autonomic function, nor concentration of glycosylated haemoglobin, are predictive of diabetic gastroparesis.

We investigated the influence of intravenous clonidine 2, 4 and 6 μg kg−1 on the electroencephalogram and on the minimal alveolar concentration of isoflurane in 40 patients aged 20–60 years undergoing elective surgery. Minimal alveolar concentration was determined using the Dixon ‘up-and-down’ method. Thirty min after the clonidine infusion anaesthesia was induced with etomidate, 0.25 mg kg−1. Skin incision was made after stable end-tidal isoflurane concentrations had been maintained for at least 15 min. Clonidine caused significant decreases in the spectral edge (95%) and median power frequency of the electroencephalogram and in the bispectral index. The minimal alveolar concentration of isoflurane decreased in a dose-dependent manner from 1.32% (95% CI, 1.28%–1.36%) in the control group to 1.03% (0.9%–1.18%) in patients given clonidine 6 μg kg−1. Clonidine 4 and 6 μg kg−1 was associated with a moderate reduction in heart rate and arterial systolic blood pressure. We recommend the use of clonidine intravenously as an adjunct to general anaesthesia in a dose of 4 μg kg−1 given 15 min before induction of anaesthesia.

Alpha-adrenergic agonists produce pain relief through an opioid independent mechanism and may be alternatives to opioids for combination with local anaesthetics for analgesia during labour. We studied 41 pregnant women. Epidural block was performed with 75 μg clonidine (n=20) or 50 μg fentanyl (n=21) combined with 0.125% bupivacaine (10 mL). Maternal vital parameters were measured. Analgesia was evaluated using a visual analogue scale (VAS); sedation was scored using a five-point scale. There were no differences in maternal vital parameters, fetal heart rate (FHR) or Apgar scores between the groups. Analgesia lasted longer in the bupivacaine-clonidine group (139.4±31 min) compared with the bupivacaine–fentanyl group (127.9±48 min) (P=0.42). Additional analgesic requirement was more often in the fentany–bupivacaine group and total bupivacaine requirement was less in the clonidine–bupivacaine group (22.5±12.5mg vs. 30.9±12.8 mg) (P=0.04). This small study confirms that this combination of bupivacaine and clonidine provides satisfactory analgesia for first-stage labour, and of longer duration than bupivacaine–fentanyl.

The aim of this study was to evaluate whether the addition of clonidine, or sufentanil, or both, to a bupivacaine solution for a caudal block prolonged the period of analgesia after operation in children. Sixty ASA class I or II boys, aged between 8 months and 13 years, admitted for hypospadias repair were enrolled into a prospective randomised study. After induction of general anaesthesia and endotracheal intubation the children were allocated into four groups. Group I received 0.5 mL kg−1 bupivacaine 0.25% caudally, in addition group II received 1 mg kg−1 clonidine, group III 0.5 mg kg−1 sufentanil and group IV 0.5 mg kg−1 clonidine and 0.25 mg kg−1 sufentanil. The concentrations of clonidine and sufentanil in group IV were halved to reduce possible side-effects with higher dosages. Analgesia and side-effects were assessed 2, 4, 6, 8 and 12 h after operation. No significant differences were found among the four groups for the pain scores at 2, 4, 6, 8 and 12 h. All groups had a similar frequency of vomiting and a comparable appetite and quality of night rest during the first 24 h following the operation. There was no signficant difference in the requirement for additional doses of analgesics. The addition of sufentanil, or clonidine, or both, to bupivacaine for caudal administration provides no additional clinical benefit over bupivacaine alone.

Adequate relaxation of the masseter muscle is important during endotracheal intubation and for the patency of a patient’s airway during recovery from anaesthesia. We evaluated onset and recovery from cisatracurium-induced neuromuscular block at the masseter and adductor pollicis muscles. Thirty patients were randomly allocated to receive either 0.1 or 0.15 mg kg−1 cisatracurium. The evoked response was measured at both muscles using acceleromyography. Onset time was significantly shorter at the masseter muscle than at the adductor pollicis (0.1 mg kg−1 cisatracurium: 155±52 vs. 229±44 s; 0.15 mg kg−1 cisatracurium: 105±24 vs. 174±35 s). Following 0.1 mg kg−1 cisatracurium, recovery to a TOF-ratio of 0.7 was faster at the masseter compared to the adductor pollicis (P < 0.05). In the 0.15 mg kg−1 cisatracurium group recovery of T1 to 75% of control and to a TOF-ratio of 0.7 occurred sooner at the masseter (P < 0.05). We conclude that onset and recovery from cisatracurium neuromuscular block occurs more rapidly at the masseter than at the adductor pollicis. It appears unlikely that residual paralysis is present at the masseter once neuromuscular function at the adductor pollicis has completely recovered.

This prospective, double-blind, randomized study assessed effect of pre-emptive peritonsillar block in 30 ASA–I children, aged 6–12 years, of both sexes, scheduled for tonsillectomy. Patients were divided into three groups: those in group I received a sham block, whereas peritonsillar blocks with bupivacaine 0.25% were given to the children before tonsillectomy (group II) or immediately after surgery had been completed (group III). Constant pain, pain on swallowing, blood glucose, serum epinephrine and norepinephrine concentrations were measured immediately after surgery and 4 h after operation. Patients in group I experienced more pain (P < 0.05) than those in groups II and III, both in the immediate postoperative period and over the next 4 h. Patients in groups II and III experienced similar pain (P > 0.05). The pain experienced when water was swallowed was similar to that of the constant pain. The rise of serum norepinephrine concentration in group II was significantly less (P < 0.05) compared to groups I and III. We found both pre-emptive and postoperative block to be equally effective in treating postoperative pain, with pre-emptive block being more effective in preventing the rise in norepinephrine concentration.

A retrospective survey was undertaken of 142 adults who had undergone cardiac surgery with cardiopulmonary bypass. According to the manufacturer's instructions for thromboelastography, patients were identified as showing evidence of fibrinolysis if after coming off bypass the Ly30 index was ≥7.5%. In the 20 fibrinolytic patients, fibrinolysis was readily corrected by tranexamic acid but these patients needed more colloid and more vasopressor support than the non-fibrinolytic patients. There were three deaths, all in the fibrinolytic patients. It is possible that fibrinolysis is a marker for onset of systemic inflammation syndrome. It is recommended that, until the association between fibrinolysis and worse outcome is investigated further, patients showing fibrinolysis early after cardiopulmonary bypass should not be discharged too soon from intensive care.

Tramadol is a weak centrally acting analgesic and it might provide efficacious postoperative pain relief with minimal sedative effects in the use of intravenous patient-controlled analgesia (PCA). Sixty women scheduled to undergo microvascular breast reconstruction under standard general anaesthesia were enrolled in a study on the performance of patient-controlled analgesia with tramadol or morphine with special emphasis on drug- and technique-related side-effects. Seven patients were re-operated within the same day, leaving 25 patients in the tramadol group and 28 in the morphine group for comparison. When postoperative pain occurred, loading doses of either 10mg tramadol or 1mg morphine intravenous increments were administered in a double-blind fashion until the pain control was judged to be satisfactory by the patient. After that the patients received tramadol or morphine by a PCA apparatus (lockout 5 min, tramadol 450 μg kg−1, morphine 45 μg kg−1 bolus). In addition, all patients received 500mg paracetamol rectally, three times a day. The potency ratio of tramadol to morphine was found to be between 8.5 : 1 (loading) and 11 : 1 (PCA). There was neither a significant difference between the groups in the overall satisfaction of the analgesic medication nor in the visual analogue and verbal rate scales for pain. Women in the tramadol group had more nausea and vomiting during the administration of loading doses (P < 0.05) and more patients in the tramadol group (7) than in the morphine group (3)(NS) wanted to discontinue the PCA therapy before the end of the study due to nausea. Sedation or blurred vision prevented the performance of the psychomotor tests in 22 and 32% of the tramadol and morphine patients, respectively. The remaining patients performed similarly in the Digit Symbol Substitution Test. In women receiving intravenous PCA for analgesia after microvascular breast reconstruction tramadol and morphine provided comparable postoperative analgesia with similar sedative effects. However, tramadol was associated with a disturbingly high incidence of nausea and vomiting.