bluuebunny/crossref_metadata_2025 huggingface dataset:
The influence of transoesophageal echocardiography on intra‐operative decision makingA European multicentre study
Authors: Kolev N. , Brase R. , Swanevelder J. , Oppizzi M. , Riesgo M. J. , Van Der Maaten J. M. A. A. , Abiad M.‐G. , Guarracino F. , Zimpfer M. ,   the European Perioperative TOE Research Group
Published: March 2003

The role of transoesophageal echocardiography (TOE) in anaesthesia remains controversial because it is a rapidly evolving technique with few proven benefits and considerable cost. Recently, the Society of Cardiovascular Anaesthesiologists has published practice guidelines for the use of peri‐operative TOE. To determine the current role of transoesophageal echocardiography and the relative impact of category‐based transoesophageal echocardiographic indications the present study investigated its use in seven Western European countries. The study sample was taken from a prospective cohort of 224 patients with acute or chronic haemodynamic disturbances or at risk of myocardial ischaemia. All patients were monitored with two‐lead electrocardiography and radial and pulmonary artery catheters, as well as biplane or multiplane transoesophageal echocardiography. A total of 2232 clinical interventions were made in these patients. The most frequently observed intervention was the administration of a fluid bolus (45% of all interventions). Overall, transoesophageal echocardiography was the most important guiding factor in 560 (25%) interventions. It was the most important monitor in guiding the following therapeutic interventions: anti‐ischaemic therapy — 207 of 372 interventions (56%); fluid administration — 275 of 996 (28%) interventions; vasopressor or inotrope administration — 56 of 316 (16%) interventions; vasodilator therapy — six of 142 (4%) interventions and depth of anaesthesia — four of 211 (2%) interventions. We found that transoesophageal echocardiography is frequently influential in guiding clinical decision making and is used most frequently for category II indications but category I indications were associated with more frequent change in management.
Isoflurane concentrations using uncompensated vaporisers within circle systems
Authors: Brosnan S. , Royston B. , White D.
Published: March 2003

In a series of studies designed to investigate the need for a temperature‐compensated vaporiser for use in a circle system, we first studied temperature changes within and isoflurane concentration delivered by a Komesaroff vaporiser during bench tests using different gas flows. Agent temperature and vapour concentration decreased as predicted by the Antoine equation. Using the vaporiser within a circle system during clinical anaesthesia, we then studied 20 patients breathing spontaneously and a further 10 patients receiving controlled ventilation, measuring the temperature of the agent within the vaporiser and the concentration of agent inspired by the patient. In clinical use with the fresh gas flows of 1–3 l.min−1, the inspired agent concentration did not decrease despite the decrease in temperature of the liquid isoflurane in the vaporiser.
Respiratory feedback effects on vaporisers in circle systems
Authors: White D. , Royston B.
Published: March 2003

We studied a group of spontaneously breathing patients anaesthetised for routine orthopaedic surgery using a circle system and isoflurane in a Komesaroff vaporiser within the circle. We observed and recorded: (1) the change in inspired isoflurane concentration caused by changing the fresh gas flow, (2) the increased respiration produced by surgical stimulus and the resulting increase in isoflurane concentration, (3) the respiratory depression produced by opioids and the consequent decrease in isoflurane concentration. We consider this regulation of anaesthetic uptake by the patient to be beneficial.
Post‐thoracotomy paraplegia coincident with epidural anaesthesia
Authors: Bhuiyan M. S. , Mallick A. , Parsloe M.
Published: March 2003

We report a case of paraplegia in the immediate postoperative period following right bilobectomy for carcinoma of the lung. An epidural catheter had been inserted following induction of anaesthesia and an infusion of bupivacaine 0.15% was used for postoperative pain relief. Magnetic resonance imaging failed to reveal any spinal or epidural haematoma or spinal cord ischaemia. The patient developed respiratory failure on the third postoperative day and required assisted ventilation. He was weaned from the ventilator on day 15. Two days later he sustained a cardiac arrest and died. Post‐mortem examination demonstrated spinal cord infarction and severely stenosed spinal arteries. The thoracotomy position and/or intra‐operative hypotension might have compromised the blood flow to the spinal cord and although suspected as a possible cause, the use of epidural analgesia was not implicated.
Insertion of the Combitube airway with the cervical spine immobilised in a rigid cervical collar
Authors: Mercer M. H. , Gabbott D. A.
Published: March 2003

The Combitube is a twin lumen device designed to establish the airway after blind insertion. Under general anaesthesia a rigid cervical collar was used to immobilise the neck in 15 ASA 1 and 2 patients. Insertion of the Combitube airway was then attempted. In 10/15 (66%) patients, blind insertion was not possible. In 5/15 (33%) successful blind insertions the Combitube entered the oesophagus on each occasion. In 8/10 of the failures, re‐insertion of the Combitube was attempted with the aid of a Macintosh laryngoscope. In 6/8 cases (75%) satisfactory placement was then possible with the Combitube again entering the oesophagus on each occasion. Ventilation was satisfactory in all patients when insertion was successful. Blood staining of the Combitube was present in 7/15 (47%) patients. The Combitube cannot be recommended for use in patients whose necks are immobilised in rigid cervical collars.
The laryngeal mask airway as an aid to training in fibreoptic nasotracheal endoscopy
Authors: Osborn N. A. , Jackson A. P. F. , Smith J. E.
Published: March 2003

We have investigated the extent to which the laryngeal mask airway, when used as an aid to fibreoptic nasotracheal video‐endoscopy training, could reduce endoscopy apnoeic time in anaesthetised, paralysed oral surgery patients. Twenty anaesthetic trainees were randomly allocated to the laryngeal mask airway or control group. Laryngeal mask airway group endoscopies were performed in three stages following insertion of the laryngeal mask airway: stage 1: nasendoscopy, with the lungs ventilated automatically through the laryngeal mask airway; stage 2: removal of the laryngeal mask airway; stage 3: pharyngoscopy, larygoscopy and tracheoscopy. Control group endoscopies were performed conventionally, in one stage. Each trainee performed five nasotracheal intubations. Though total endoscopy time in the laryngeal mask airway group (stage 1 + stage 2 + stage 3 times) was significantly longer (average 136 s vs. 108 s), apnoeic time (stage 2 + stage 3 times) was significantly shorter (average 59 s vs. 108 s) than endoscopy time in the control group. This application of the laryngeal mask airway may have a useful role to play in ensuring patient safety during early fibreoptic training.
Suxamethonium and mivacurium sensitivity from pregnancy‐induced plasma cholinesterase deficiency
Authors: Davies P. , Landy M.
Published: March 2003

A fit 36‐year‐old parturient received a general anaesthetic for manual removal of a retained placenta. She underwent rapid sequence induction of anaesthesia with suxamethonium, shortly followed by 10 mg of mivacurium. One hour later she had failed to establish adequate ventilation despite administration of drugs to reverse neuromuscular blockade. A provisional diagnosis of suxamethonium‐related apnoea was made and her lungs were ventilated overnight on the Intensive Care Unit. Plasma cholinesterase levels at the time were reduced to one‐third of normal, with normal dibucaine and fluoride numbers. One month later her levels were back within the reference range.
Use of capnography delaying the diagnosis of tracheal intubation
Authors: Chan Y. K. , Zuraidah S. , Tan P. S. K.
Published: March 2003

There was a delay in making the correct diagnosis of tracheal intubation in a parturient who developed severe bronchospasm after intubation because we relied on the capnogram.
Evaluation of intubating conditions with rocuronium and either propofol or etomidate for rapid sequence induction
Authors: Skinner H. J. , Biswas A. , Mahajan R. P.
Published: March 2003

We have assessed the effect of two induction agents on tracheal intubating conditions after rocuronium 0.6 mgkg−1 in unpremedicated patients undergoing simulated rapid sequence induction. Following pre‐oxygenation, anaesthesia was induced with propofol up to 2.5 mgkg−1 (n = 35) or etomidate 0.3 mgkg−1 (n = 36), and further increments as required. After loss of verbal contact, cricoid pressure was applied and rocuronium was injected. Laryngoscopy was performed at 45 s and intubation attempted at 60 s after rocuronium had been given. Ninety‐four per cent of patients in the propofol group had clinically acceptable (good or excellent) intubating conditions compared to only 75% in the etomidate group (p = 0.025). Owing to coughing, one patient in the etomidate group could not be intubated on the first attempt. A greater pressor response also followed intubation after induction with etomidate. We conclude that etomidate and rocuronium alone cannot be recommended for intubation at 60 s under rapid sequence induction conditions.
Epidural haematoma following anticoagulant treatment in a patient with an indwelling epidural catheter
Authors: Skilton R. W. H. , Justice W.
Published: March 2003

We report the occurrence of an epidural haematoma after the removal of a lumbar epidural catheter, which had been inserted 2 days previously for surgery to revise a thrombosed femoral–popliteal graft. Pre‐operatively the patient received intravenous heparin by infusion, but this was stopped 7 h prior to epidural insertion. Coagulation studies were normal. The epidural catheter insertion was unremarkable. Postoperatively, the patient received a continuous epidural infusion of fentanyl (3 μg.ml−1) and bupivacaine (0.0625%), in addition to systemic anticoagulant therapy with heparin. On the second postoperative day, the patient was noted to have developed bilateral leg weakness (following transfer to another department for Doppler studies). The epidural catheter was inadvertently removed while the patient was anticoagulated and paraparesis developed overnight. After a significant delay, an epidural haematoma was diagnosed and treated by decompressive laminectomy. At operation an epidural haematoma extending posteriorly from T12 to L3 was removed.
The physiological and pharmacological roles of cytochrome P450 isoenzymes
Authors: Chang G. W. M. , Kam P. C. A.
Published: March 2003

The cytochrome P450 isoenzymes are a superfamily of haemoprotein enzymes that catalyse the metabolism of a large number of endogenous and exogenous compounds. Recently, the cytochrome isoenzymes have been shown to be important in the synthesis of steroid hormones and bile acids, the arachidonic acid cascade and in central nervous function. These enzymes are a major determinant of the pharmacokinetic behaviour of numerous drugs. Furthermore, alterations in cytochrome P450 activity have been implicated in some diseases.
The effect of intravenous tenoxicam on pruritus in patients receiving epidural fentanyl
Authors: Colbert S. , O'Hanlon D. M. , Chambers F. , Moriarty D. C.
Published: March 2003

In this prospective randomised study, pruritus and pain were evaluated in patients undergoing abdominal surgery during which epidural fentanyl was administered. All patients had an epidural catheter inserted at the time of surgery. Epidural fentanyl 100 μg was administered intra‐operatively and infused at a concentration of 2 μgml−1 for 48 h postoperatively. All patients received a standard anaesthetic and, in addition, the study group had a 20 mg bolus of tenoxicam intravenously, intra‐operatively. Patients receiving tenoxicam demonstrated significantly lower pruritus and pain scores at 30 min, 2, 4, 8 and 24 h postoperatively as well as reduced pethidine requirements for breakthrough pain in the first 24 h. In conclusion, tenoxicam 20 mg significantly reduces the incidence and severity of postoperative pruritus in patients who received peri‐operative epidural fentanyl. In addition, it significantly reduces pain and further analgesic requirements postoperatively.
The analgesic efficacy of tramadol versus ketorolac in day‐case laparoscopic sterilisation
Authors: Putland A. J. , McCluskey A.
Published: March 2003

We conducted a prospective, randomised, double‐blind study to compare the analgesic efficacy of intravenous tramadol 1.5 mg.kg−1 and ketorolac 10 mg in 60 ASA grade 1 and 2 patients scheduled to undergo day‐case laparoscopic sterilisation by application of Filshie clips. Patients who received tramadol had significantly less postoperative pain in the recovery room (p = 0.007) and at discharge from the day‐surgery unit (p = 0.03), and they required rescue analgesia with morphine less often (p = 0.02) than patients who received ketorolac. No difference in either the incidence or severity of nausea and vomiting was observed between the two groups. Both analgesic drugs were well tolerated at the doses given in the study, although dry mouth was significantly more common after the administration of tramadol (p = 0.009). Three patients in the tramadol group and five in the ketorolac group required overnight admission due to pain or nausea and vomiting.
The effect of intrathecal magnesium sulphate on nociception in rat acute pain models
Authors: Ishizaki K. , Sasaki M. , Karasawa S. , Obata H. , Nara T. , Goto F.
Published: March 2003

We examined the antinociceptive effect of intrathecally administered magnesium sulphate (MgSO4) in rats, using acute pain models including mechanical pressure, heat and subcutaneous formalin injection. According to the locomotion test 10 μl of 6.2% MgSO4 did not produce motor paralysis. At the same dose, responses to pressure and heat were intact, compared with controls given saline. MgSO4 produced depression of pain responses only after the first 10 min in the formalin test. Our studies indicated that MgSO4 did not show remarkable antinociceptive effects in acute pain models.
Prevention of needle‐stick injuryEfficacy of a safeguarded intravenous cannula
Authors: Asai T. , Matsumoto S. , Matsumoto H. , Yamamoto K. , Shingu K.
Published: March 2003

One possible method of reducing the incidence of needle‐stick injury is to use needles with safeguard mechanisms. The needle of the Insyte AutoGuard intravenous cannula can be retracted into the safety barrel. One hundred patients were randomly allocated to receive either an 18‐gauge conventional Insyte intravenous cannula (group C) or the AutoGuard cannula (group AG) to assess the ease of use and efficacy of the AutoGuard device. It was possible to insert the cannula into the vein within two attempts in all patients; there was no significant difference between two groups with respect to ease of insertion. No problems, such as inadvertent withdrawal of the needle, occurred during insertion in any patient. Handling the withdrawn needle was judged significantly safer in group AG than in group C (p < 0.001). Blood contamination often occurred where a withdrawn needle was placed in group C, whereas no blood stain was detected in any case in group AG (p < 0.001). The AutoGuard cannula provides safer handling of a withdrawn needle without reducing its ease of insertion.
Effects of nitrous oxide on haemodynamic and electroencephalographic responses induced by tetanic electrical stimulation during propofol anaesthesia
Authors: Inada T. , Shingu K. , Nakao S. , Nagata A.
Published: March 2003

We studied the effect of nitrous oxide on haemodynamic and electroencephalographic responses caused by noxious stimulation during propofol anaesthesia. Thirty‐four patients (ASA I–II) were anaesthetised with propofol 3 mgkg−1 and were randomly allocated to receive either 60% nitrous oxide in oxygen or 40% oxygen in air. Anaesthesia was maintained using propofol infusion of 10 mgkg−1.h−1 for the first 10 min, 8 mgkg−1.h−1 for the next 10 min and 6 mgkg−1.h−1 thereafter. Thirty minutes after the induction of anaesthesia, tetanic electrical stimulation (80 mA, 100 Hz) was applied to the ulnar nerve. Tetanic stimulation significantly increased blood pressure and heart rate in both groups (p < 0.005 or less), but did not induce any arousal pattern on the electroencephalograph. Nitrous oxide significantly attenuated the tetanic stimulation‐induced increase in blood pressure (p < 0.05 or less), but not the heart rate.
The effect of cerebral palsy on the action of vecuronium with or without anticonvulsants
Authors: Hepağuşlar H. , Özzeybek D. , Elar Z.
Published: March 2003

Patients with cerebral palsy who are treated with anticonvulsant medication are resistant to vecuronium. We examined the contributions to vecuronium resistance made by cerebral palsy and anticonvulsants in a study of children with cerebral palsy and a control group. The acceleromyographic responses of the following three groups of children were studied: children with cerebral palsy not taking anticonvulsant medication (n = 11); children with cerebral palsy taking anticonvulsant medication (n = 8); and a control group of children who did not have cerebral palsy and were not taking anticonvulsant treatment (n = 10). Using a standardised technique, general anaesthesia was induced and maintained with 0.5–1.5% isoflurane in a 60/40 nitrous oxide in oxygen mixture. After a stabilisation period which was performed with supramaximal train‐of‐four stimuli (2 Hz every 15 s) an intubating dose of vecuronium 0.1 mgkg−1 was administered. The first twitch of the train‐of‐four response (T1), the onset time, the times to 25, 50, 75 and 90% recovery of T1, recovery index, and the time to 70% recovery of train‐of‐four ratio were recorded. Recovery times to T1 and train‐of‐four responses were reduced significantly in both groups of children with cerebral palsy compared with the control group. These results suggest that children with cerebral palsy display resistance to vecuronium whether or not they are taking anticonvulsant drugs.
Effect of maternal ambulation on labour with low‐dose combined spinal–epidural analgesia
Authors: Collis R. E. , Harding S. A. , Morgan B. M.
Published: March 2003

Two hundred and twenty‐nine nulliparous women who requested regional analgesia during labour were given a combined spinal–epidural block. They were randomly allocated to stay in bed or spend at least 20 min of every hour out of bed. There was no significant difference in duration of labour, analgesia requirements, mode of delivery or condition of the baby between the groups. Ambulation appeared to be safe for the mother and baby. Maternal satisfaction with the low‐dose combined spinal–epidural was high in both groups.
Cervical spine movements during laryngoscopyComparison of the Macintosh and McCoy laryngoscope blades
Authors: MacIntyre P. A. , McLeod A. D. M. , Hurley R. , Peacock C.
Published: March 2003

We studied cervical spine movement in 10 patients scheduled for elective surgery under general anaesthesia. Each patient was fitted with a rigid cervical collar before undergoing direct laryngoscopy for orotracheal intubation. Laryngoscopy was performed using the McCoy laryngoscope in the activated position and the standard Macintosh blade. Displacement of the cervical spine at laryngeal exposure was measured using lateral cervical spine X‐rays. Flexion and extension movements of the cervical spine during the use of the two laryngoscope blades were compared. For each blade, the greatest degree of extension occurred at the joint between the first and second cervical vertebrae. There was no significant difference in cervical spine movement when the two blades were compared.
A comparison of anaesthetic tensions in arterial blood and oxygenator exhaust gas during cardiopulmonary bypass
Authors: Lockwood G. G. , Sapsed‐Byrne S. M. , Adams S.
Published: March 2003

This study evaluates the usefulness of the analysis of gas sampled from the exhaust port of a membrane oxygenator in the estimation of anaesthetic tension in arterial blood. Sixty‐seven arterial blood samples were drawn from patients undergoing hypothermic cardiopulmonary bypass with anaesthesia maintained by either isoflurane or desflurane. Anaesthetic tensions in the oxygenator exhaust gas were measured using an infrared analyser and in arterial blood using a two‐stage headspace technique with a gas chromatograph. Both measurement systems were calibrated with the same standard gas mixtures. There was no difference in anaesthetic tension measured in arterial blood and gas leaving the oxygenator exhaust (isoflurane: n = 29, range: 0.3–0.8%, 95% limits of agreement: − 0.08% to 0.09%; desflurane: n = 38, range: 1.5–5.4%; 95% limits of agreement − 0.65% to 0.58%). We conclude that anaesthetic tensions in arterial blood can be accurately monitored by analysis of the gas emerging from the exhaust port of a membrane oxygenator.
The ‘dedicated airway’: a review of the concept and an update of current practice
Authors: Charters P. , O'Sullivan E.
Published: March 2003

The term ‘dedicated airway’ was ifrst used in connection with nasal fibreoptic intubations using the cuffed nasopharyngeal airway. Since that time, the concept has developed and the term has been extended to include fibreoptic intubation techniques involving both the laryngeal mask airway and cuffed oropharyngeal airway. ‘Dedicated airway’ can now be defined as: ‘An upper airway device dedicated to the maintenance of airway patency while other major airway interventions are anticipated or are in progress. The device should be compatible with spontaneous and controlled ventilation. ‘Dedicated airway techniques allow planned fibreoptic intubations in difficult cases and provide an emergency airway option in an unexpected difficult intubation when the alternative may be to wake the patient. As well as promoting safe conditions for training fibreoptic intubation in general, there is the particular advantage of being able to train using these techniques in patients known to be difficult to intubate. The authors' evolved clinical experiences in promoting the concept and the rlevant literature are reviewed.
Effect of cricoid pressure on gastro‐oesophageal reflux in awake subjects
Authors: Skinner H. J. , Bedforth N. M. , Girling K. J. , Mahajan R. P.
Published: March 2003

This study aimed to evaluate whether cricoid pressure is associated with a high risk of gastro‐oesophageal reflux. Fifteen awake, fasted volunteers were studied. A cricoid pressure of 44 N was applied for 60 s by resting a padded yoke over the cricoid cartilage. Using continuous oesophageal pH monitoring, no volunteer had gastro‐oesophageal reflux during cricoid pressure, although one subject had a reflux spike soon after relieving cricoid pressure. We conclude with 95% confidence that the incidence of gastro‐oesophageal reflux during cricoid pressure is not more than 20%.
Target‐controlled remifentanil in combination with propofol for spontaneously breathing day‐case patients
Authors: Murdoch J. A. C. , Hyde R. A. , Kenny G. N. C.
Published: March 2003

Remifentanil is a new potent opioid with a very short duration of action irrespective of duration of infusion. It may have a role in day‐case anaesthesia as part of a balanced total intravenous anaesthetic technique with propofol. We examined the respiratory depressant effects of remifentanil in 20 patients undergoing day‐case anaesthesia. The target plasma concentration of remifentanil was varied while maintaining a constant target‐controlled infusion of 4.5 μg.ml−1 propofol. In only 12 patients was satisfactory spontaneous respiration maintained. In these patients the median remifentanil target concentration was 1.6 ng.ml−1 and was achieved with a median infusion rate of 0.05 μg.kg−1.min−1. The range of target concentrations associated with satisfactory spontaneous respiration was wide and varied over a 4.7‐fold range from 0.6 to 2.8 ng.ml−1.
Provision of training in chronic pain management for specialist registrars in the United Kingdom
Authors: Huggins L. J. , Ward S. P. , Stannard C. F.
Published: March 2003

A study published in 1992 highlighted wide variations in the provision of training in pain management. In this survey, data were collected from both pain clinicians and Programme Directors of the Schools of Anaesthesia to see if there had been any changes in training patterns since the introduction of the Calman training scheme. There did not seem to be a uniform improvement in the provision of training in pain management for Specialist Registrars and many may reach their Certificate of Completion of Specialist Training without a basic knowledge of chronic pain. It is thought that at the present time there will be few Specialist Registrars with sufficient training to take up consultant posts in pain management unless they compete for the much sought after, and often not fully funded, pain fellowships outside their rotations.
Hyperbaric oxygen therapy in the management of severe acute anaemia in a Jehovah's Witness
Authors: McLoughlin  , Cope  , Harrison
Published: March 2003

A case is described in which a Jehovah's Witness patient who refused blood transfusion suffered massive antepartum haemorrhage, her haemoglobin falling as low as 2.0 g.dl−1. She was treated on an intensive care unit with intermittent positive pressure ventilation and general supportive measures, pulsed hyperbaric oxygen therapy and recombinant human erythropoietin.
Testing of adult and paediatric ventilators for use in a magnetic resonance imaging unit
Authors: Williams E. J. , Jones N. S. , Carpenter T. A. , Bunch C. S. , Menon D. K.
Published: March 2003

We have assessed the performance of a series of ventilators (modified versions of the ventiPAC, paraPAC and babyPAC ventilators; SIMS pneuPAC Ltd, Luton, UK) in a magnetic resonance imaging (MRI) scanning environment, with MR safety and compatibility issues being addressed. Following initial modifications to remove ferromagnetic components and replace them with MR‐safe materials, all three ventilators performed well in a series of tests in static magnetic fields up to 2 T. Ventilator performance was unaffected by static fields, switching gradients or radio frequency fields within the MR suite. Furthermore, the devices produced no degradation of image quality when used during MR scanning. We discuss management strategies for the care of critically ill ventilated patients during MR procedures.
A cuff pressure controller for tracheal tubes and laryngeal mask airways
Authors: Abdelatti M. O.
Published: March 2003

A simple device (U.K. Patent application no. 9907876.8) for fine adjustment of the cuff pressure of tracheal tubes and the laryngeal mask airway is described. In vitro tests confirm its efficiency. It is also a simple tool for training anaesthetic assistants in the operating theatre and nurses in the intensive care unit.
A comparison of the effect of rocuronium and vecuronium on heart rate during gynaecological laparoscopy
Authors: Harvey A. , Anderson L. , Broome I. J.
Published: March 2003

The effect on intra‐operative heart rate of two nondepolarising muscle relaxants, rocuronium and vecuronium, was compared in 116 fit out‐patients undergoing gynaecological laparoscopic procedures. Both groups received an anaesthetic technique which differed only in the choice of muscle relaxant. Intra‐operatively it was noted that patients given rocuronium (20 mg) had significantly fewer episodes of bradycardia (heart rate < 50 beat.min−1) than patients given vecuronium 4 mg (p < 0.05). Profound bradycardias (heart rate < 30 beat.min−1) did not occur in any of the patients in the rocuronium study group, whereas 5% of patients receiving vecuronium had a period of transient asystole. We conclude that, at the doses stated, rocuronium results in significantly fewer episodes of bradycardia than vecuronium when used as a muscle relaxant for laparoscopic gynaecological procedures.
Speed of onset of regional analgesia in labour: a comparison of the epidural and spinal routes
Authors: Nickells J. S. , Vaughan D. J. A. , Lillywhite N. K. , Loughnan B. , Hasan M. , Robinson P. N.
Published: March 2003

This study compares the speed of onset of effective analgesia in two randomly assigned groups of patients requesting analgesia in labour. Patients in the combined spinal–epidural group (n = 69) were given a subarachnoid injection of 1.5 ml containing bupivacaine 2.5 mg and fentanyl 25 μg for initiation of analgesia. Patients in the epidural group (n = 73) were given an epidural injection of 10 ml containing bupivacaine 12.5 mg and fentanyl 50 μg. Mean (SD) onset times to the first pain‐free contraction were 10.0 (5.7) min in the combined spinal–epidural group and 12.1 (6.5) min in the epidural group (p = 0.054). Patients in the combined spinal–epidural group suffered a higher incidence of motor weakness and proprioceptive deficit than those in the epidural group (p = 0.01). The incidence of technique failure and side‐effects was similar in the two groups. It is our contention that the statistically nonsignificant difference in onset times does not justify the additional potential for side‐effects and the extra cost of the equipment involved in the combined spinal–epidural technique.
Combined spinal–epidural techniques
Authors: Cook T. M.
Published: March 2003

The combined spinal–epidural technique has been used increasingly over the last decade. Combined spinal–epidural may achieve rapid onset, profound regional blockade with the facility to modify or prolong the block. A variety of techniques and devices have been proposed. The technique cannot be considered simply as an isolated spinal block followed by an isolated epidural block as combining the techniques may alter each block. This review concentrates on technical and procedural aspects of combined spinal–epidural. Needle‐through‐needle, separate‐needle and combined‐needle techniques are described and modifications discussed. Failure rates and causes are reviewed. The problems of performing a spinal block before epidural blockade (potential for unrecognised placement of an epidural catheter, inability to detect paraesthesia during epidural placement, difficulty in testing the epidural, delay in positioning the patient) are described and evaluated. Problems of performing spinal block after epidural blockade (risk of catheter or spinal needle damage) are considered. Mechanisms of modification of spinal blockade by subsequent epidural drug administration are discussed. The review considers choice of technique, needle type, patient positioning and paramedian vs. midline approach. Finally, complications associated with combined spinal–epidural are reviewed.
The effect of cricoid pressure on the cricoid cartilage and vocal cords: an endoscopic study in anaesthetised patients
Authors: Palmer J. H. MacG. , Ball D. R.
Published: March 2003

Cricoid pressure is used to protect the lungs from contamination with gastric contents during tracheal intubation. We studied the effect of cricoid pressure applied with a yoke on 30 anaesthetised patients examined fibreoptically through a laryngeal mask airway. We assessed the effect of 20, 30 and 44 N on the internal appearance of the cricoid and vocal cords. Difficulty in ventilation was also recorded. At 44 N, cricoid deformation occurred in 27/30 patients (90%) and 15/30 (50%) had cricoid occlusion [13/30 (43%) had cricoid occlusion at 30 N and 7/30 (23%) at 20 N]. Associated difficulty in ventilation was present in 15 patients (50%) and 18/30 (60%) had vocal cord closure with associated difficult ventilation, at forces up to 44 N. Cricoid occlusion was unrelated to age and body mass index but females were at greater risk. Orthodox values of cricoid pressure, applied with a yoke, may produce obstruction at the level of the cricoid cartilage or vocal cords, with implications for tracheal intubation and ventilation by mask.
Anaesthesia for magnetic resonance imaging: a survey of current practice in the UK and Ireland
Authors: McBrien M. E. , Winder J. , Smyth L.
Published: March 2003

The lack of information about standards for anaesthetic practice in magnetic resonance imaging is of concern, since increasing requests are being made for this service, often in units not designed for the purpose. An overview of current practice was sought by conducting a postal survey of magnetic resonance units in the UK and Ireland. Replies were received from 100 units (79%), 46 of which had an anaesthetic service provided. A wide diversity of practice and opinion on the conduct of anaesthesia in this field was evident from the replies received. The survey highlighted particular areas of concern about the personal safety of anaesthetists within such units, including exposure to magnetic fields, noise and unscavenged anaesthetic gases. The evidence for such concerns is reviewed.
Carotid endarterectomyA survey of UK anasthetic practice
Authors: Knighton J. D. , Stoneham M. D.
Published: March 2003

We conducted a postal questionnaire survey of the members of the Vascular Anasthesia Society of Great Britain and Ireland, asking questions about the provision of anasthesia for carotid endartectomy. Of 215 respondents, 187 were currently providing anasthesia for carotid endarterectomy. The majority of respondents (69%) always use general anasthesia for this operation but 99/215 (46%) had some experience of regional anasthesia for carotid endartectomy. Amongst those currently using regional anasthesia, combined deep and superficial cervical plexus block was the technique used by 71%. Other regional techniques used included local infiltration and superficial block alone. During regional anasthesia, most (66%) anasthetists used cerebral monitoring techniques such as stump pressure or transcranial Doppler as well as keeping the patient awake. However, in a significant proportion of cases (37%) under general anasthesia no cerebral monitoring was used. Reported surgical shunt insertion rates were lower in awake (mean 42%) patients than those receiving general anasthesia (61%). Respondents using regional anasthesia were more likely to feel that their technique was appropriate than those using general anasthesia.
Comparison of remifentanil versus regional anaesthesia in children anaesthetised with isoflurane/nitrous oxide
Authors: Prys‐Roberts C. , Lerman J. , Murat I. , Taivainen T. , Lopez T. , Lejus C. , Spahr‐Schopfer I. , Splinter W. , Kirkham A. J. T.
Published: March 2003

We compared the efficacy and safety of a remifentanil (0.25 µg.kg−1.min−1)‐based balanced anaesthetic technique with a bupivacaine‐based regional anaesthetic technique in an open label, multicentre study in 271 ASA physical status 1 or 2 children aged 1–12 years. Subjects requiring major intra‐abdominal, urological or orthopaedic surgery were randomly allocated to receive either intravenous remifentanil (group R; n = 185) or epidural bupivacaine (group B; n = 86) with isoflurane/nitrous oxide for their anaesthesia. The majority of children in both groups (85% in group R, 78% in group B) showed no defined response to skin incision, and although the mean increase in systolic blood pressure (+11 mmHg) was significantly greater in group R than in group B, this change did not represent a serious haemodynamic disturbance. More children in group R (31%) required interventions to treat hypotension and/or bradycardia than those in group B (12%), but these were easily managed by administration of fluids or anticholinergic drugs. Adverse events, mainly nausea and/or vomiting, occurred in 45% of group R and 42% of group B (NS). The adverse event profile of remifentanil in this study was typical of a potent µ‐opioid receptor agonist. Remifentanil was as effective as epidural or caudal block in providing analgesia and suppressing physiological responses to surgical stimuli in children aged between 1 and 12 years undergoing major abdominal, urological, or orthopaedic surgery under isoflurane/nitrous oxide anaesthesia.
The safety and efficacy of cisatracurium 0.15 mg.kg−1 during nitrous oxide–opioid anaesthesia in infants and children
Authors: Taivainen T. , Meakin G. H. , Meretoja O. A. , Wirtavuori K. , Perkins R. J. , Murphy A. K. , Fisher G. R. , Waiter M. R. D.
Published: March 2003

We studied the neuromuscular and cardiovascular effects of a single, rapidly administered intravenous dose of cisatracurium 0.15 mg.kg−1 in 27 infants (aged 1–23 months) and 24 children (aged 2–12.5 years). After midazolam premedication, anaesthesia was induced and maintained with thiopental and alfentanil in addition to nitrous oxide in oxygen. Neuromuscular function was monitored by evoked adductor pollicis electromyography. At least 15 min after intubation, each patient received cisatracurium 0.15 mg.kg−1 over 5 s. Complete neuromuscular blockade was produced by this dose in all but one infant. The mean (SD) onset time of maximal blockade was more rapid in infants [2.0 (0.8) min] than in children [3.0 (1.2) min], p = 0.0011. The clinical duration of action of cisatracurium (recovery of evoked response to 25% of control) was significantly longer in infants [43.3 (6.2) min] than in children [36.0 (5.4) min], p < 0.0001. Once neuromuscular function started to recover, the rate of recovery was similar in both age groups. Changes in blood pressure and heart rate after the administration of cisatracurium were negligible in both age groups. Cisatracurium, at a dose of 0.15 mg.kg−1, was effective and well tolerated in infants and children.
Inadequate pre‐operative evaluation and preparation: a review of 197 reports from the Australian Incident Monitoring Study
Authors: Kluger M. T. , Tham E. J. , Coleman N. A. , Runciman W. B. , Bullock M. F. M.
Published: March 2003

The Australian Incident Monitoring Study database was examined for incidents involving inadequate pre‐operative patient preparation and/or evaluation. Of 6271 reports, 727 had appropriate keywords, of which 197 (3.1%) were used for subsequent analysis. All surgical categories were represented. In 10% of reports the patient was not reviewed pre‐operatively by an anaesthetist, whilst in 23% the anaesthetist involved in the operating theatre had not performed the pre‐operative assessment. Death followed in seven cases, major morbidity in 23 cases, admission to a high‐dependency unit or intensive care unit in 17 cases, and surgery was cancelled in nine cases. Poor airway assessment, communication problems and inadequate evaluation were the most common contributing factors. Respondents indicated that the incident was preventable in 57% of cases. Proposed corrective strategies include improved communication, quality assurance activities, development of protocols and additional training. A structured assessment of the airway, along with improvements in information exchange, patient assessment, and use of clearly defined patient management plans and pathways would prevent most of the incidents reported.
Validation of outcome prediction in elderly patients
Authors: Jandziol A. K. , Ridley S. A.
Published: March 2003

We recently described an equation for predicting the 1‐year survival of critically ill patients aged over 70 years. The aim of this study was to check the performance of this equation in a validation group of 555 patients. The required demographic details (age, diagnosis, acute physiology score) of all elderly patients admitted between 1/4/95 and 31/9/96 were recorded and patients were followed for 1 year. One hundred and six patients died on the intensive care unit (19% mortality) and a further 134 died within 1 year (43% total 1‐year mortality). The performance of the predictive equation was modest; the goodness‐of‐fit p‐value was 0.04 and the area under the receiver operating characteristic curve was 0.75. For both groups, the combined 1‐year survival of all critically ill elderly patients was 55% but the outcome of patients aged over 85 years remains poor (37%).
Glycinothorax: a new complication of transurethral surgery
Authors: Pittman J. A. L. , Dirnhuber M.
Published: March 2003

A 76‐year‐old woman sustained inadvertent perforation of her posterior bladder wall during transurethral resection of a bladder tumour. In the immediate postoperative period, she developed life‐threatening respiratory failure following the formation of a large, unilateral pleural effusion. After therapeutic drainage, biochemical analysis of the effusion revealed that it had a high concentration of glycine. The fluid used for intra‐ and postoperative bladder irrigation had leaked from the perforated bladder and collected in the pleural cavity. This type of hydrothorax complicating endoscopic urological surgery has not been described previously.
Effect of cricoid pressure on the incidence of nausea and vomiting in the immediate postoperative period
Authors: Khan F. A. , ul Haq A.
Published: March 2003

This study aimed to evaluate whether the application of cricoid pressure at the time of induction of anaesthesia was associated with a lesser incidence of postoperative nausea or vomiting in the immediate postoperative period compared with a group in which no cricoid pressure was applied, in patients undergoing day care gynaecological laparoscopy. One hundred ASA I and II females were randomly allocated to receive cricoid pressure at the time of induction. The peri‐operative anaesthetic technique was standardised. The incidence of postoperative nausea and vomiting in the group who received cricoid pressure was 16% in the recovery room compared with 26% in the no cricoid group. When the period was extended to the first 6 h post anaesthesia the incidence was 30% in the cricoid and 44% in the no cricoid group. This difference did not achieve statistical significance in either period (p > 0.05). The results suggest that application of cricoid pressure at the time of induction does not significantly alter the incidence of postoperative nausea and vomiting in the first 6 h of recovery from anaesthesia.
Sevoflurane inhalation conscious sedation for children having dental treatment
Authors: Lahoud G. Y. G. , Averley P. A. , Hanlon M. R.
Published: March 2003

An audit at the Queensway Anxiety Management Clinic of 2014 children, referred for dental treatment, showed that relative analgesia by inhalation of nitrous oxide and oxygen failed in 40% of cases successfully to complete treatment. We therefore investigated the efficacy of a new inhalation conscious sedation technique, which reduced the need for general anaesthesia. Seventy‐five children aged 3–15 years were given inhalation conscious sedation, with sevoflurane 0.1–0.3% and nitrous oxide 40% in oxygen. In 69 children (92%), the dental treatment was completed successfully. Most children (93%) had recovered fully within 10 min without side‐effects. Treatment was fully accepted by 88% of children and 91% of their parents. The use of sevoflurane in low concentrations to supplement nitrous oxide and oxygen for conscious sedation in children appears to be safe and effective and further study is currently in progress.
Patient‐controlled analgesia and postoperative nausea and vomiting: efficacy of a continuous infusion of ondansetron
Authors: White L. A. , Vanarase M. , Brockbank K. , Barrett R. F.
Published: March 2003

A continuous infusion of ondansetron was compared with a placebo infusion in 80 patients undergoing major breast reconstructive surgery. All patients received a standard anaesthetic and a bolus dose of ondansetron after induction. They were then randomly allocated to receive an intravenous infusion of ondansetron or a placebo infusion for 24 h in a double‐blind fashion. Postoperative analgesia was provided by patient‐controlled subcutaneous diamorphine. In the ondansetron group, the severity of nausea, measured by a 10‐point verbal rating scale, was reduced (p = 0.01) and fewer patients stated at postoperative interview that nausea and vomiting was a problem (p = 0.01).
Accuracy and reliability of APACHE II scoring in two intensive care units
Authors: Polderman K. H. , Girbes A. R. J. , Thijs L. G. , Strack van Schijndel R. J. M.
Published: March 2003

Acute Physiology and Chronic Health Evaluation (APACHE) II scoring is widely used as an index of illness severity, for outcome prediction, in research protocols and to assess intensive care unit performance and quality of care. Despite its widespread use, little is known about the reliability and validity of APACHE II scores generated in everyday clinical practice. We retrospectively re‐assessed APACHE II scores from the charts of 186 randomly selected patients admitted to our medical and surgical intensive care units. These ‘new’ scores were compared with the original scores calculated by the attending physician. We found that most scores calculated retrospectively were lower than the original scores; 51% of our patients would have received a lower score, 26% a higher score and only 23% would have remained unchanged. Overall, the original scores changed by an average of 6.4 points. We identified various sources of error and concluded that wide variability exists in APACHE II scoring in everyday clinical practice, with the score being generally overestimated. Accurate use of the APACHE II scoring system requires adherence to strict guidelines and regular training of medical staff using the system.
Effect of midazolam pretreatment on induction dose requirements of propofol in combination with fentanyl in younger and older adults
Authors: Cressey D. M. , Claydon . P. , Bhaskaran N. C. , Reilly C. S.
Published: March 2003

In a double‐blind, randomised trial, we compared the effects of pretreatment with midazolam at two different doses (0.025 and 0.05 mg.kg−1), with placebo, on the induction dose requirements of propofol in two different age groups. We enrolled 120 patients: 60 younger patients (aged 18–35 years) and 60 older patients (aged over 60 years). All patients received 0.75 µg.kg−1 of fentanyl, plus a blinded pretreatment with either saline or one of two doses of midazolam. Induction continued with a fixed rate infusion of propofol. Propofol dose requirement was recorded, as were cardiovascular parameters and the occurrence of significant apnoea (> 60 s). Midazolam pretreatment was associated with a significant reduction in propofol dose requirement in both younger and older patients. The reduction in older patients was significantly greater than the equivalent response in younger groups. There was no demonstrable benefit in terms of improved cardiovascular stability or reduction in the incidence of apnoea. Caution is advised in the use of midazolam as an agent for co‐induction with propofol in the elderly.
A study of bispectral analysis and auditory evoked potential indices during propofol‐induced hypnosis in volunteersThe effect of an episode of wakefulness on explicit and implicit memory
Authors: Barr G. , Anderson R. E. , Jakobsson J. G.
Published: March 2003

The bispectral index (BIS) and the auditory evoked potential (AEP) index as calculated by the new A‐line monitor were measured during hypnosis with propofol, which included an episode of wakefulness. Both indices followed a similar pattern during sedation, with values decreasing with sedation and increasing when awake. Baseline AEP values varied between 60 and 98, and BIS values were between 96 and 98. The AEP‐index value was at all times 10–20 points lower than the BIS‐index. The transition to loss of response occurred at a mean AEP value of 46 and BIS value of 58. The transition to just responding following a period of unconsciousness occurred at a mean AEP value of 46 and BIS 65. Both monitoring techniques, however, displayed large interindividual variations making it impossible to discriminate in real time between subtle changes of clinical state. The new neurophysiological monitors A‐line AEP and BIS are interesting tools for creating a better understanding of the anaesthetic effects of drugs; however, further refinements are required before their relative roles can be fully established in the clinical setting.