bluuebunny/crossref_metadata_2025 huggingface dataset:
Acupuncture in the management of chronic pain
Authors: Woollam C. H. M. , Jackson A. O.
Published: March 2003

This article reports the results of a survey of acupuncture practice in chronic pain clinics in the United Kingdom. The survey reveals that acupuncture is widely used in the treatment of chronic pain with 84% of those responding stating that it was available at their clinics. The majority of practitioners had attended a course at one of the ‘acupuncture schools’ but in about one fifth of the clinics the practitioner had not received any formal training.
Experiences and attitudes of consultant and nontraining grade anaesthetists to continuing medical education (CME)
Authors: Heath K. J. , Jones J. G.
Published: March 2003

A questionnaire survey was sent to 164 consultant anaesthetists with the aim of investigating their experiences and attitudes to continuing medical education. The response rate was 79%. Most anaesthetists were motivated to achieve the required number of credits and for the majority of anaesthetists, regional, national and internal departmental discussion meetings were the mainstay of educational activities. The educational standard of available activities could be improved to include more workshop‐style learning opportunities and to make journal reading a creditable continuing medical education activity. The place of research is questioned. There was doubt as to whether sanctions such as withdrawing recognition for training should be imposed on departments where some anaesthetists fail to achieve the required number of credits and whether this would motivate anaesthetists to achieve the set standards. Continuing medical education was felt to be effective and the main barriers to attending educational activities are discussed.
Caesarean section following a recent retinal haemorrhage
Authors: Chidley K. E. , Law R. , Vanner R. G.
Published: March 2003

We report a case of a 32‐year‐old woman who developed an antenatal Valsalva‐induced retinal haemorrhage causing unilateral blindness 38 weeks into her pregnancy. Delivery was achieved by elective Caesarean section under epidural anaesthesia. The influence of anaesthetic technique on a recent retinal haemorrhage is discussed.
The effect of acupuncture on the incidence of postextubation laryngospasm in children
Authors: Lee C. K. , Chien T. J. , Hsu J. C. , Yang C. Y. , Hsiao J. M. , Huang Y. R. , Chang C. L.
Published: March 2003

Laryngospasm occurring after tracheal extubation in children is potentially dangerous. This study uses acupuncture with bloodletting at the Shao Shang (L 11) or Shang Yang (Li 1) acupoints to investigate whether this technique can prevent or treat laryngospasm. Seventy‐six patients were randomly divided into two groups. Patients in the acupuncture group (n = 38) were treated with bilateral Shao Shang acupunctures at the end of the operation. Patients in the control group (n = 38) were not. The incidence of laryngospasm in the acupuncture group (5.3%) was less than that in the control group (23.7%) (p < 0.05). If laryngospasm developed, patients were immediately treated with acupuncture at either the Shao Shang or Shang Yang acupoints. As judged by an increase in peripheral oxygen saturation, the laryngospasm was relieved within 1 min of acupuncture in all patients. It is concluded that acupuncture with bloodletting at the Shao Shang acupoint may prevent and treat laryngospasm occurring after tracheal extubation in children.
Peri‐operative tolerance to large‐dose 6% HES 200/0.5 in major urological procedures compared with 5% human albumin
Authors: Vogt N. , Bothner U. , Brinkmann A. , de Petriconi R. , Georgieff M.
Published: March 2003

We studied the long‐term efficacy and safety of medium‐molecular‐weight hydroxyethyl starch (HES) administered in doses above 20 mlkg−1 during major blood replacement therapy. Blood replacement for 50 patients used 6% HES 200/0.5 (HES group) or 5% albumin (ALB group) and additional blood components according to a defined protocol. We compared safety, efficacy and costs in 4 peri‐operative days. Colloid administration on the day of surgery was 38.4 mlkg−1 (HES group) and 35.1 mlkg−1 (ALB group). Haemodynamic, coagulation and renal function parameters were similar. Although total serum protein was still different on the third postoperative day (53.45 gl−1 (HES group) and 60.6 gl−1 (ALB group) (p < 0.01)) the colloid osmotic pressure always remained above 19.5 (2.5) mmHg (HES group). Blood loss (3810 (1632) ml (HES group) and 3455 (1733) ml (ALB group)) and the requirement for blood components was comparable. Costs were reduced by 35% (p < 0.05) in the HES group. We conclude that using 6% HES 200/0.5 as the only colloid for treatment even of large blood loss is a safe and economic alternative to albumin.
Laryngeal mask airway intracuff pressure estimation by digital palpation of the pilot balloon: a comparison of reusable and disposable masks
Authors: Keller C. , Brimacombe J. R.
Published: March 2003

Digital palpation of the pilot balloon provides information about the intracuff pressure of the laryngeal mask airway. The purpose of this in vitro study was to evaluate this technique for the reusable and disposable laryngeal mask airway. Ten anaesthetists and 10 recovery‐unit nurses estimated intracuff pressures from low/high initial pressures before/after training. In the pretraining phase, the mean (95% CI) pressure was 99 (94–105) cmH2O, but this was significantly lower for the reusable laryngeal mask airway (91 vs. 103 cmH2O) and if the initial pressure was low (81 vs. 112 cmH2O). In the post‐training phase, there was a significant overall improvement to 75 (66–85) cmH2O, but target pressures remained more accurate if the initial pressure was low. Subjects in the training group could estimate 95% of pressures for both devices to within ±10 cmH2O of the target if the initial pressure was low. We conclude that anaesthetists and recovery‐unit nurses are capable of accurate estimation of intracuff pressures using the digital palpation technique following a brief period of training.
Cricoid pressure: knowledge and performance amongst anaesthetic assistants
Authors: Meek T. , Gittins N. , Duggan J. E.
Published: March 2003

We investigated the cricoid pressure technique of 135 anaesthetic assistants attending the annual conference of the British Association of Operating Department Assistants in May 1997. Their knowledge and training were assessed using a structured interview. Technique was assessed using a simulator measuring applied force during sham cricoid pressure. Our additional aims were to see whether a knowledge of the required force and practical training in the application of a target force would affect performance. Our results highlight a lack of knowledge relating to the manoeuvre. Only about one‐third of subjects could quote an appropriate force and fewer than half could give a single contraindication to its use. Very few subjects had been trained on a model before practising the technique on a patient. Technique was poor and we observed a large variation in the force actually applied. Performance, as assessed by the variability of forces applied and proportion of subjects applying force within our target range (30–44 N), was improved markedly by providing simple instruction about the required force in an understandable form. Performance was further improved by practical training in the application of target force on a simulator.
Anaesthesia for Conn's syndrome
Authors: Winship S. M. , Winstanley J. H. R. , Hunter J. M.
Published: March 2003

We describe the peri‐operative management of two patients undergoing bilateral adrenalectomy for Conn's syndrome; one using an open surgical approach and the other a laparoscopic technique. The first patient, aged 64 years, died of a myocardial infarction 5 days postoperatively; the second, aged 29 years, had an uneventful recovery. The pre‐operative preparation, peroperative management and postoperative care of these patients are detailed, and the pathophysiology and clinical management of Conn's syndrome are reviewed.
The immediate impact of opening an adult high dependency unit on intensive care unit occupancy
Authors: Fox A. J. , Owen‐Smith O. , Spiers P.
Published: March 2003

We assessed the hourly occupancy of our intensive care and high dependency units over an 8‐week period commencing on the day our high dependency unit opened. Using criteria established by the working group on ‘Guidelines on Admission to and Discharge from Intensive Care and High Dependency Units’ published by the National Health Service Executive, we defined each patient daily as intensive care or high dependency status. Compared with hourly occupancy figures obtained before the high dependency unit opened, occupancy of the intensive care unit by high dependency patients has been shown to decrease significantly from 21.6% to 11.2%. Use of intensive care beds became more appropriate, their occupancy increasing significantly from 63.7% to 73.4%. A significant decrease in readmissions occurred, supporting the hypothesis that having high dependency beds reduces the number of patients discharged prematurely to the wards.
Eating in labour. A randomised controlled trial assessing the risks and benefits
Authors: Scrutton M. J. L. , Metcalfe G. A. , Lowy C. , Seed P. T. , O'Sullivan G.
Published: March 2003

The aim of this study was to determine whether permitting women in labour to eat a light diet would: (i) alter their metabolic profile, (ii) influence the outcome of labour, and (iii) increase residual gastric volume and consequent risk of pulmonary aspiration. Women were randomised to receive either a light diet (eating group, n = 48) or water only (starved group, n = 46) during labour. The light diet prevented the rise in plasma β‐hydroxybutyrate (p = 2.3 × 10−5) and nonesterified fatty acids (p = 9.3 × 10−7) seen in the starved group. Plasma glucose (p = 0.003) and insulin (p = 0.017) rose in the eating group but there was no difference in plasma lactate (p = 0.167) between the groups. There were no differences between the groups with respect to duration of first or second stage of labour, oxytocin requirements, mode of delivery, Apgar scores or umbilical artery and venous blood samples. Relative gastric volumes estimated by ultrasound measurement of gastric antral cross‐sectional area were larger (p = 0.001) in the eating group. This was supported by the observation that those from this group who vomited, vomited significantly larger volumes than those in the starved group (p = 0.001). We conclude that eating in labour prevents the development of ketosis but significantly increases residual gastric volume.
Evaluation of the SCOTI device for confirming blind nasal intubation
Authors: Trikha A. , Singh C. , Rewari V. , Arora M. K.
Published: March 2003

The sonomatic confirmation of tracheal intubation (SCOTI) is a new device used to confirm the correct placement of tracheal tubes. It utilises a sonic technique for recognition of a resonating frequency for detection of tracheal intubation. We compared its predictive value with that of the clinical auscultatory method and a capnograph to confirm 132 blind nasal intubations using three different tracheal tubes [red rubber (n = 82), polyvinyl chloride (n = 33) and RAE preformed nasal (n = 17)]. SCOTI correctly identified 70.8% of intubations and chest auscultation did so 99.2% of times. All results were confirmed using a capnograph. The SCOTI device gave a false‐negative value in 37 patients (28%) and a false‐positive result in two patients (1.5%). The response time for confirming intubations was 2.5 (1.5) s for the SCOTI, 4.1 (1.1) s for a capnograph and 40 (9.4) s for the auscultatory method. The erroneous results shown by the SCOTI device were highest when polyvinyl chloride tubes with a Murphy's eye were used for intubation. This study shows that this device is not very useful for ascertaining the correct placement of tracheal tubes after blind nasal intubation.
Why do patients feel positive about patient‐controlled analgesia?
Authors: Chumbley G. M. , Hall G. M. , Salmon P.
Published: March 2003

We studied 200 patients to identify the aspects of their experience of patient‐controlled analgesia (PCA) that made them feel ‘extremely positive’ about this technique. After PCA had been withdrawn, patients completed a questionnaire which included the following topics: pre‐operative information, pain relief, the degree of control that PCA afforded the patient, side‐effects and safety. Multiple regression analysis identified three factors of their experience which were associated uniquely with feeling ‘extremely positive’ about PCA: having better pain relief, not worrying about ‘giving oneself too much drug’ and not experiencing feeling ‘peculiar in the head’. Control over pain relief, although highly correlated with feeling ‘extremely positive’ about PCA, was unimportant when these variables were controlled. Because of the well‐recognised difficulties in measuring satisfaction with analgesic regimens, we suggest that a satisfaction score based on these variables would be a significant advance on existing methods.
Ambient pressure oxygen reservoir apparatus for use during one‐lung anaesthesia
Authors: Pfitzner J. , Peacock M. J. , Daniels B. W.
Published: March 2003

An ambient pressure oxygen reservoir bag apparatus for connecting to the nonventilated lung as soon as single‐lung ventilation is initiated is described. The theoretical benefits are the facilitation of collapse of the lung on the side of surgery and a reduced likelihood of arterial desaturation. Although these main benefits are yet to be proven, the authors believe that the weight of theoretical argument and practical observation serves to justify the use of the apparatus while the outcome of suitably designed clinical trials is awaited. It can be used for all one‐lung anaesthetics and is especially recommended for thoracoscopic surgery, where temporary re‐expansion of the nonventilated lung is either counter‐productive or contraindicated, and where there is a possibility that lung collapse may be delayed.
Intravenous buscopan for analgesia following laparoscopic sterilisation
Authors: Wilson C. M. , Lillywhite N. , Matta B. , Mills P. , Wiltshire S.
Published: March 2003

Following reports that tubal smooth muscle spasm may contribute to pelvic pain following laparoscopic sterilisation, we studied the effect of buscopan (an anticholinergic agent used to relieve smooth muscle spasm) on 45 patients undergoing general anaesthesia for day‐case laparoscopic sterilisation. Patients were randomly allocated to receive either buscopan 20 mg or saline placebo after induction of anaesthesia. There were no significant differences in pain scores or postoperative analgesic requirements between the two groups. We conclude that intravenous buscopan confers no benefit in day‐case laparoscopic sterilisation.
The pre‐operative ECG in day surgery: a habit?
Authors: Murdoch  , Murdoch  , McIntyre  , Hosie  , Clark
Published: March 2003

As the population presenting for day‐case surgery and anaesthesia increases, so does the challenge of adequate pre‐operative assessment. Although an electrocardiogram is frequently performed, its value in day‐case surgery remains unproven. One thousand, one hundred and eighty‐five patients presenting for day‐case surgery were assessed. One hundred and fifty‐four (13%) were referred for electrocardiogram according to well‐recognised criteria for the prediction of coronary artery disease. They were read independently by the anaesthetist responsible for the case and by an experienced cardiologist. A significant abnormality was noted in 26% of electrocardiograms, most frequently in patients referred with hypertension. There was a good correlation between the reports of the anaesthetist and cardiologist. Only 20% of those patients with an abnormal electrocardiogram had their surgery postponed. No adverse events occurred in patients proceeding to surgery despite the abnormalities. We conclude that a resting electrocardiogram is of limited value in risk stratification of patients undergoing day‐case surgery.
The effect of pre‐emptive acupuncture treatment on analgesic requirements after day‐case knee arthroscopy
Authors: Gupta S. , Francis J. D. , Tillu A. B. , Sattirajah A. I. , Sizer J.
Published: March 2003

The role of acupuncture analgesia in the management of postoperative pain is yet to be clearly evaluated. We conducted a prospective, double‐blind, randomised controlled study to evaluate the effect of acupuncture pretreatment on the analgesic requirement after knee arthroscopy. Forty‐two patients presenting for unilateral knee arthroscopy were randomly allocated to receive a standard anaesthetic with or without acupuncture (given after the induction of anaesthesia). Visual analogue pain scores, time to first postoperative analgesia and total analgesia requirement in the first 24 h were recorded. There was no significant difference between the two groups in any of the outcome measures. We conclude that acupuncture analgesia has no additional effect when given under anaesthesia to patients undergoing knee arthroscopy.
Anaesthesia and pain management in cerebral palsy
Authors: Nolan J. , Chalkiadis G. A. , Low J. , Olesch C. A. , Brown T. C. K.
Published: March 2003

Cerebral palsy is the result of an injury to the developing brain during the antenatal, perinatal or postnatal period. Clinical manifestations relate to the area affected. Some of the conditions associated with cerebral palsy require surgical intervention. Problems during the peri‐operative period may include hypothermia, nausea and vomiting and muscle spasm. Peri‐operative seizure control, respiratory function and gastro‐oesophageal reflux also require consideration. Intellectual disability is common and, in those affected, may range from mild to severe. These children should be handled with sensitivity as communication disorders and sensory deficits may mask mild or normal intellect. They should be accompanied by their carers at induction and in the recovery room as they usually know how best to communicate with them. Postoperative pain management and the prevention of muscle spasm is important and some of the drugs used in the management of spasm such as baclofen and botulinum toxin are discussed. Epidural analgesia is particularly valuable when major orthopaedic procedures are performed.
Heat loss during induction of anaesthesia for elective aortic surgery
Authors: Stoneham M. , Howell S. , Neill F.
Published: March 2003

We have studied core temperature changes occurring during induction of general anaesthesia and surgery in 18 patients undergoing elective aortic aneurysm repair. In the operating theatre, all patients were warmed with a forced‐air warmer and a warming mattress, and received warmed (37 °C) intravenous fluids. Despite this, mean (SD) [range] core temperatures in the anaesthetic room decreased by 1.5 (0.3)[1.1–2.2] °C, while intravascular lines, epidural and urinary catheters were inserted before the introduction of warming methods in theatre. In one‐third of patients, the core temperature was still below 36 °C at the end of surgery. The overall temperature decrease correlated significantly with the duration of time between induction of general anaesthesia and surgical incision (R2 = 0.6912), when the patients were not being warmed. Hypothermia may thus be prevented by minimising the period that the patient is anaesthetised without being warmed. Vascular lines, urinary and epidural catheters should be inserted before the induction of general anaesthesia or, alternatively, warming methods should be introduced in the anaesthetic room.
Airway obstruction with cricoid pressure
Authors: Hartsilver E. L. , Vanner R. G.
Published: March 2003

Cricoid pressure may cause airway obstruction. We investigated whether this is related to the force applied and to the technique of application. We recorded expired tidal volumes and inflation pressures during ventilation via a facemask and oral airway in 52 female patients who were anaesthetised and about to undergo elective surgery. An inspired tidal volume of 900 ml was delivered using a ventilator. Ventilation was assessed under five different conditions: no cricoid pressure, backwards cricoid pressure applied with a force of 30 N, cricoid pressure applied in an upward and backward direction with a force of 30 N, backwards cricoid pressure with a force of 44 N and through a tracheal tube. An expired tidal volume of < 200 ml was taken to indicate airway obstruction. Airway obstruction did not occur without cricoid pressure, but did occur in one patient (2%) with cricoid pressure at 30 N, in 29 patients (56%) with 30 N applied in an upward and backward direction and in 18 (35%) patients with cricoid pressure at 44 N. Cricoid pressure applied with a force of 44 N can cause airway obstruction but if cricoid pressure is applied with a force of 30 N, airway obstruction occurs less frequently (p = 0.0001) unless the force is applied in an upward and backward direction.
Haemoconcentration by gelatin‐induced acceleration of erythrocyte sedimentation rate
Authors: Sümpelmann R. , Günther A. , Zander R.
Published: March 2003

Erythrocyte sedimentation rates from 40 suspensions of packed red blood cells in modified fluid gelatin, 4% albumin solution, 6% hydroxyethyl starch and normal saline were measured at room temperature using Westergren's method. The erythrocyte sedimentation rate was extremely high in gelatin and this increase was significant after 10–60 min when compared with the other fluids. Erythrocyte sedimentation rates in albumin, hydroxyethyl starch and normal saline were low and there were no differences between these fluids [erythrocyte sedimentation after 60 min, median (interquartile range): gelatin 128 (111.2–130.0) mm, albumin 2 (1.5–2.0) mm, hydroxyethyl starch 1.5 (1.0–1.6) mm, normal saline 2 (1.9–2.5) mm, p < 0.0001]. The addition of twice the volume of modified fluid gelatin to a volume of red blood cells leads to rapid acceleration of the erythrocyte sedimentation rate. This is caused by increased erythrocyte aggregation, and in clinical practice this effect may be useful for the haemoconcentration of diluted blood from cardiopulmonary bypass circuits or cell‐saver autotransfusion in paediatric surgery.
A prospective randomised controlled study of patient‐controlled propofol sedation in phobic dental patients
Authors: Girdler N. M. , Rynn D. , Lyne J. P. , Wilson K. E.
Published: March 2003

The safety and effectiveness of patient‐controlled propofol sedation was prospectively assessed in 18 healthy, phobic dental patients. Using a randomised, crossover design each patient received two sessions of equivalent dental treatment under patient‐controlled or clinician‐controlled propofol sedation. The patient‐controlled technique used 29.8% less drug (time‐weighted dose) than the clinician‐controlled method (p = 0.011). There was a high correlation between number of demands and number of doses actually infused during the patient‐controlled technique (r = 0.99, p < 0.001). Clinically, the level of sedation was lighter and the degree of operator satisfaction was higher with patient‐controlled sedation. Blood pressure and arterial oxygen saturation showed minimal changes and remained within normal ranges during both techniques. Patient‐controlled sedation produced a greater reduction in dental and general anxiety compared with clinician‐controlled sedation, but the difference did not reach statistical significance. Three times the number of patients expressed a preference for the patient‐controlled, compared with the clinician‐controlled, technique. Patient‐controlled sedation provides safe and acceptable intra‐operative anxiolysis for phobic dental patients, but with reduced propofol dosage.
The effect of low concentrations of halothane on the cerebrovascular circulation in young children
Authors: Paut O. , Lazzell V. A. , Bissonnette B.
Published: March 2003

To determine the effect of halothane on cerebral blood flow velocity measured by transcranial Doppler, 23 healthy young children were studied during surgery. Anaesthesia was induced with thiopental, fentanyl and vecuronium, and maintained with halothane in 70% nitrous oxide in oxygen. A continuous epidural anaesthesia with 0.25% bupivacaine was performed. End‐tidal carbon dioxide pressure, temperature, heart rate and systolic blood pressure were kept constant. Three minimal alveolar concentrations (MAC; 0.5, 1.0 and 1.5) of halothane were administered in stepwise increases. The cerebral blood flow velocity increased significantly at 1.0 (p < 0.01) and 1.5 MAC (p < 0.001) compared with the value at 0.5 MAC. No further change in cerebral blood flow velocity was seen between 1.0 and 1.5 MAC. These data show that maximal changes in cerebral blood flow velocity are obtained at 1.0 MAC and that further increases in halothane concentration do not modify the cerebral circulation. It is suggested that young children differ from adults in that the maximal effect of halothane occurs at lower concentrations.
Early release pattern of S100 protein as a marker of brain damage after warm cardiopulmonary bypass
Authors: Shaaban Ali M. , Harmer M. , Vaughan R. S. , Dunne J. , Latto I. P.
Published: March 2003

Warm blood cardioplegia may be more beneficial to the heart than cold cardioplegia, but the effects of warm cardiopulmonary bypass and warm blood cardioplegia on the brain are controversial. S100 protein is an early marker of brain damage and has been detected after cold cardiopulmonary bypass. We studied S100 concentrations in 20 patients undergoing coronary artery bypass surgery before and after warm cardiopulmonary bypass (34–37 °C) using warm blood cardioplegia (37 °C) for all patients. The peak level of S100 protein occurred immediately after warm cardiopulmonary bypass, then decreased progressively until the last measurement at 4.5 h after bypass. The peak level appears to be dependent upon the age of the patient, with the following regression equation: y = −3.2 + 0.08x, where y is S100 protein concentration in µg.l−1 and x is patient age in years. Further studies are needed to investigate the clinical significance of this early release pattern. Patient age should be taken into account when studying S100 protein levels after cardiopulmonary bypass.
Long‐term survival following emergency abdominal aortic aneurysm repair
Authors: Milner Q. J. W. , Burchett K. R.
Published: March 2003

Survival following emergency surgery for ruptured abdominal aortic aneurysm remains poor and is in stark contrast to that for elective repair. We have carried out a 5‐year retrospective observational study to determine the long‐term (5‐year) survival of patients following emergency surgery for ruptured abdominal aortic aneurysm at a district general hospital in East Anglia. A total of 99 patients presented to the operating theatre for emergency repair of ruptured abdominal aortic aneurysm in this 5‐year study period. In‐hospital mortality was 70% and was unchanged over the 5 years. Overall long‐term survival in those patients discharged from hospital was good. The ICU cost per long‐term survivor was calculated to be £36 750.
The oesophageal–tracheal Combitube Small Adult™An alternative airway for ventilatory support during gynaecological laparoscopy
Authors: Hartmann T. , Krenn C. G. , Zoeggeler A. , Hoerauf K. , Benumof J. L. , Krafft P.
Published: March 2003

Airway management during gynaecological laparoscopy is complicated by intraperitoneal carbon dioxide inflation, Trendelenburg tilt, increasing airway pressures and pulmonary aspiration risk. We investigated whether the oesophageal–tracheal Combitube 37 Fr SA™ is a suitable airway during laparoscopy. One hundred patients were randomly allocated to receive either the Combitube SA™ (n = 49) or tracheal intubation (n = 51). Oesophageal placement of the Combitube was successful at the first attempt [16 (3) s]. Peak airway pressures were 25 (5) cmH2O. An airtight seal was obtained using air volumes of 55 (13) ml (oropharyngeal balloon) and 10 (1) ml (oesophageal cuff). Significant correlations were observed between patient's height and weight and the balloon volumes necessary to produce a seal. Similar findings were recorded for the control group, with tracheal intubation being difficult in three patients. The Combitube SA™ provided a patent airway during laparoscopy. Non‐traumatic insertion was possible and an airtight seal was provided at airway pressures of up to 30 cmH2O.
Nerve tissue protein S‐100 and neurone‐specific enolase concentrations in cerebrospinal fluid and blood during carotid endarterectomy
Authors: Gao F. , Harris D. N. F. , Sapsed‐Byrne S. , Standfield N. J.
Published: March 2003

Nerve tissue protein S‐100 and neurone‐specific enolase levels in serum were studied in 10 patients before, during and for 2 days after elective carotid endarterectomy performed under general anaesthesia and using a Javid Shunt. In six patients, simultaneous cerebrospinal fluid samples were also obtained. Serum nerve tissue protein S‐100 was normal throughout the operation, but in one patient with severe hypertension, levels increased to 1.38 µg.l−1 at 1 h postoperatively. Two patients showed an increase in cerebrospinal fluid nerve tissue protein S‐100 during clamping: these patients also had neurological deficits at 6 months. Serum neurone‐specific enolase increased from 5.8 to 9.3 µg.l−1 during shunting while cerebrospinal fluid neurone‐specific enolase did not change. Uncomplicated carotid endarterectomy does not produce cerebral damage as measured by serum nerve tissue protein S‐100; cerebrospinal fluid nerve tissue protein S‐100 may be more sensitive for minor cerebral damage. Neurone‐specific enolase appeared to be nonspecific. The lack of correlation between the neuroproteins may need to be explained before relying on these simple assays as diagnostic indicators of cerebral ischaemia.
The effect of halothane and isoflurane on plasma cytokine levels
Authors: Helmy S. A. K. , Al‐Attiyah R. J.
Published: March 2003

The aim of this study was to investigate the effect of halothane vs. isoflurane on cytokine production during minor elective surgery. Forty adult patients, ASA I‐II were randomly allocated to receive halothane or isoflurane. Venous samples for interleukin (IL)‐1β, IL‐2, IL‐6, tumour necrosis factor‐α (TNF‐α) and interferon‐γ (IFN‐γ) were taken before anaesthesia, before incision, at the end of anaesthesia and 24 h postoperatively. In both groups, IL‐6 and TNF‐α levels remained low throughout the study period. Before incision, in both groups IL‐1β and IFN‐γ showed a decrease (p < 0.01 for IL‐1β in isoflurane group and p < 0.05 for the others) compared with pre‐induction. By the end of anaesthesia and surgery, IL‐1β had increased significantly (p < 0.05) and IFN‐γ had decreased significantly (p < 0.05) in both groups compared with pre‐incisional levels. By 24 h postoperatively in both groups, IL‐1β had decreased significantly (p < 0.05), whereas IFN‐γ had increased significantly (p < 0.05) compared with the end of anaesthesia and surgery level. Pre‐incisionally, IL‐2 increased in the halothane group (p < 0.01), whereas it decreased significantly in the isoflurane group (p < 0.001) compared with the pre‐induction level. By the end of anaesthesia and surgery and by 24 h postoperatively, IL‐2 had decreased significantly in the halothane group (p < 0.001), whereas it increased significantly in the isoflurane group (p < 0.001) compared with pre‐incision and end of anaesthesia and surgery levels, respectively.
The sedative and electroencephalographic effects of regional anaesthesia*
Authors: Morley A. P. , Chung D. C. , Wong A. S. Y. , Short T. G.
Published: March 2003

We studied sedation scores, the processed electroencephalogram and mean arterial pressure pre‐operatively in patients before and after spinal (n = 15) and lumbar epidural (n = 15) anaesthesia. We compared them with changes occurring over time in a control group (n = 15), using the responsiveness component of the Observer Assessment of Alertness and Sedation rating scale. The electroencephalographic variables studied were bispectral index, 95% spectral edge frequency, median frequency and the power distribution between frequency bands α, β, θ and δ. No differences were detected within groups in sedation scores before and after intervention, or between groups at either stage. No between‐group differences were detected in electroencephalographic variables. In the spinal group, spinal anaesthesia caused an increase in bispectral index, 95% spectral edge frequency, median frequency and β frequencies, and a decrease in δ frequencies and mean arterial pressure. The increase in β frequencies is similar to that seen in patients with low plasma concentrations of midazolam and may represent subclinical sedation.
Efficacy of the laryngeal tube during intermittent positive‐pressure ventilation
Authors: Asai T. , Murao K. , Shingu K.
Published: March 2003

We studied the efficacy of the laryngeal tube (VBM, Germany) during intermittent positive‐pressure ventilation in 50 patients. After induction of anaesthesia and neuromuscular blockade, a size 4 laryngeal tube was inserted for patients of height 155 cm or greater. After insertion of the laryngeal tube, its pharyngeal and oesophageal balloons were inflated to an intracuff pressure of 60 cmH2O. An Ambu self‐inflating bag was attached to the laryngeal tube and the lungs were ventilated manually at 15 breath.min−1. It was possible to ventilate the lungs at the first attempt in 47 patients (94%). The airway pressure at which air leaked around the laryngeal tube exceeded 18 cmH2O in 41 patients (82%), and was > 30 cmH2O in 25 (50%). Median [interquartile range (range)] leak pressure was 30 [20–30 (6 to > 30)] cmH2O. Median [interquartile range (range)] tidal volume was 587 [533–653 (133–800)] ml or 8.8 [8.2–10.6 (1.9–12.6)] ml.kg−1. We conclude that the laryngeal tube has a potential role in airway management during intermittent positive‐pressure ventilation for anaesthesia or cardiopulmonary resuscitation.
Damage to the conus medullaris following spinal anaesthesia
Authors: Reynolds F.
Published: March 2003

Seven cases are described in which neurological damage followed spinal or combined spinal‐epidural anaesthesia using an atraumatic spinal needle. All patients were women, six obstetric and one surgical. All experienced pain during insertion of the needle, which was usually believed to be introduced at the L2−3 interspace. In all cases, there was free flow of cerebrospinal fluid before spinal injection. There was one patchy block but, in the rest, anaesthesia was successful. Unilateral sensory loss at the levels of L4–S1 (and sometimes pain) persisted in all patients; there was foot drop in six and urinary symptoms in three. Magnetic resonance imaging showed a spinal cord of normal length with a syrinx in the conus (n = 6) on the same side as both the persisting clinical deficit and the symptoms that had occurred at insertion of the needle. The tip of the conus usually lies at L1−2, although it may extend further. Tuffier's line is an unreliable method of identifying the lumbar interspaces, and anaesthetists commonly select a space that is one or more segments higher than they assume. Because of these sources of error, anaesthetists need to relearn the rule that a spinal needle should not be inserted above L3.
A case of extensive block with the combined spinal‐epidural technique during labour
Authors: Shaw I. C. , Birks R. J. S.
Published: March 2003

The increasing use of combined spinal‐epidural analgesia in obstetric practice has arisen from a desire to achieve a rapid onset of analgesia while reducing the intensity of the motor block. Although the procedure has an excellent safety profile, as with any technique there are potential problems. Difficulty in assessing the position of the epidural catheter after establishment of the spinal blockade may lead to an abnormally extensive block when a full‐strength local anaesthetic solution is used. We present a case in which the use of 0.5% bupivacaine to top‐up the epidural component of a combined spinal‐epidural resulted in a total spinal block. The possible causes of this complication are discussed.
Coronary artery bypass graft surgery in a patient with haemoglobin SC disease
Authors: Marchant W. A. , Wright S. , Porter J. B.
Published: March 2003

Patients with sickle cell disease who undergo surgery are generally considered to be at greater risk of peri‐operative complications than otherwise healthy patients. We report a case of a woman with haemoglobin SC disease undergoing coronary artery bypass grafting. She was successfully managed with pre‐operative exchange transfusion and normothermic cardiopulmonary bypass.
Pulmonary oedema after ophthalmic regional anaesthesia in an unfasted patient undergoing elective surgery
Authors: Taylor I. , Watters M.
Published: March 2003

An elderly female patient presenting for phaco‐emulsification and intra‐ocular lens implant under local anaesthesia developed pulmonary oedema after surgery and underwent emergency tracheal intubation. The pulmonary oedema may have been caused by her omission of routine oral diuretic medication before surgery and having to lie flat for the procedure. The patient had not been fasted before surgery, as is accepted practice in many hospitals. This made emergency tracheal intubation potentially hazardous. The patient made a full recovery. The issues of pre‐operative assessment, fasting and the withholding of diuretic medication before elective eye surgery under local anaesthesia are discussed.
Descriptive patient data as an explanation for the variation in average daily costs in intensive care
Authors: Jacobs P. , Edbrooke D. , Hibbert C. , Fassbender K. , Corcoran M.
Published: March 2003

Intensive care patients require therapy that can vary considerably in type, duration and cost, so making it extremely difficult to predict patient resource use. Few studies measure actual costs; usually average daily costs are calculated and these do not reflect the variation in resource use between individual patients. The aim of this study was to analyse a data set of 193 critically ill adult patients to look for associations between routinely collected descriptive data and patient‐specific costs. Regression analysis was used to explore any relationships between average daily patient‐specific costs and the following variables: duration of intensive care unit stay, Acute Physiology and Chronic Health Evaluation II scores in the first 24 h, gender, age, mechanical ventilation at any point during the stay, postoperative status, emergency admission and mortality. Overall, this analysis explained 33.6% of the variation in average daily costs. The additional costs of an extra day of care, mechanical ventilation, an extra point on the Acute Physiology and Chronic Health Evaluation II score, and survival were obtained.
A pharmacokinetic model for factor VIII dosing during active haemorrhage in patients with haemophilia A
Authors: Ho A. M.‐H. , Dion P. , Karmakar M. K. , Cheng G. , Derrick J. L. , Chung D. C. , Tay B. A.
Published: March 2003

A theoretical one‐compartment pharmacokinetic model is described, the aim of which is to guide factor VIII replacement therapy in patients with haemophilia A suffering from significant and ongoing haemorrhage. Based on our calculations, plasma factor VIII concentrations can decrease at a rapid rate even with non‐severe blood loss.
Combined pre‐incisional oral dextromethorphan and epidural lidocaine for postoperative pain reduction and morphine sparing: a randomised double‐blind study on day‐surgery patients
Authors: Weinbroum A. A. , Lalayev G. , Yashar T. , Ben‐Abraham R. , Niv D. , Flaishon R.
Published: March 2003

The reduction in acute pain perception following dextromethorphan has previously been investigated in patients undergoing general anaesthesia. This random and double‐blind study examined the effects of pre‐incisional oral dextromethorphan on postoperative pain and intravenous patient‐controlled morphine demand in 60 day‐surgery patients undergoing lower body surgery under lidocaine (1.6%−16 ml) epidural anaesthesia after receiving placebo, 60 or 90 mg dextromethorphan, 90 min pre‐operatively. Postoperative pain was scored on a visual analogue scale from 1 to 10. In‐hospital observation continued for 6 h and for 3 days at home; diclofenac was available throughout. Dextromethorphan‐treated patients reported significantly (p < 0.05) less pain and sedation, and felt better. Patients who received dextromethorphan 90 mg had significantly (p < 0.05) lower heart and respiratory rates than those who received 60 mg. Medicated patients required half the morphine and diclofenac of placebo patients: 38% of patients who received 90 mg and 21% who received dextromethorphan 60 mg used no morphine or diclofenac whatsoever, a previously unreported finding.
Hypertension as a risk factor for cerebral injury during cardiopulmonary bypass
Authors: Schmidt M. , Scheunert T. , Steinbach G. , Schirmer U. , Marx T. , Freitag N. , Reinelt H.
Published: March 2003

We studied 22 patients aged 53–78 years scheduled for cardiac surgery under cardiopulmonary bypass. Blood pressure, cardiac output, transcranial Doppler blood flow velocity, arterial blood gases, body temperature and protein S100B, as a marker for cerebral integrity, were evaluated in normotensive and hypertensive patients. Pre‐operative mean (SD) arterial blood pressure was 93 (11) mmHg in the normotensive group compared with 116 (15) mmHg in the hypertensive group. We found an increase in protein S100B levels in both groups. Serum protein S100B concentrations in the hypertensive group were significantly higher than in the normotensive group (p < 0.001). The highest mean (SD) values were 2.04 (0.65) µmol.l−1 in the normotensive group and 7.02 (4.55) µmol.l−1 in the hypertensive group. These results suggest that cardiopulmonary bypass is associated with a significantly higher rate of cerebral injury in hypertensive patients than in normotensive patients. This may be due to altered autoregulation and insufficient cerebral perfusion. Modifications of cardiopulmonary bypass management for hypertensive patients might be made to decrease the risk of cerebral injury.
A comparison of patient‐controlled analgesia administered by the intravenous or intranasal route during the early postoperative period
Authors: Ward M. , Minto G. , Alexander‐Williams J. M.
Published: March 2003

Intranasal administration of lipophilic opioids has been shown to be an effective method of administration which is devoid of major side‐effects. Whether it is as effective as intravenous administration for patientcontrolled analgesia (PCA) has been investigated for fentanyl and pethidine, but not for diamorphine. This study reports a randomised controlled trial designed to compare the effectiveness of diamorphine administered as PCA utilising either the intranasal or intravenous routes. We investigated 52 consecutive patients undergoing primary lower limb joint replacement surgery. Patients were randomly allocated to receive PCA diamorphine, administered either intravenously (0.5 mg bolus, 3 min lockout) or intranasally (1.0 mg bolus, 3 min lockout). Pain was assessed using a Visual Analogue Score (VAS) at rest and on movement on five occasions over the first 36 h postoperatively. The results demonstrated that patients in the intranasal PCA group had significantly higher VAS scores than the intravenous group, both at rest (intranasal median 35.5 vs. intravenous median 20; p = 0.030) and on movement (intranasal median 64 vs. intravenous median 50; p = 0.016). However, significantly fewer patients in the intranasal group compared with the intravenous group suffered episodes of vomiting (intranasal 0/24 vs. intravenous 6/24 patients; p = 0.022). We suggest that if a maximal reduction in pain score is considered the goal of PCA management, the intravenous route is preferable to the intranasal route.
Maternal cardiovascular consequences of positioning after spinal anaesthesia for Caesarean section: left 15° table tilt vs. left lateral
Authors: Rees S. G. O. , Thurlow J. A. , Gardner I. C. , Scrutton M. J. L. , Kinsella S. M.
Published: March 2003

Sixty healthy women undergoing elective Caesarean section were randomly allocated to either a measured 15° left table tilt position (n = 31) or full left lateral position (n = 29) for a 15‐min period after spinal blockade. Arm and leg blood pressure, ephedrine requirements, symptoms, fetal heart rate, cord gases and Apgar scores were recorded. Mean ephedrine requirements and incidence of hypotension were similar in the two groups. Arm systolic arterial pressure over time was similar in both groups, but leg systolic arterial pressure over time was significantly lower in the tilt group (p < 0.001); the mean leg systolic arterial pressure was lower for all 15 sequential recordings in the tilt group, reaching statistical significance (p < 0.05) at 4, 5, 6 and 8 min. Differences in maternal nausea, vomiting and bradycardia and fetal outcome were not statistically significant. Following spinal anaesthesia, even a true 15° left table tilt position is associated with aortic compression.
A novel method of measuring cricoid force*
Authors: Clayton T. J. , Vanner R. G.
Published: March 2003

Summary The application of cricoid pressure is an effective means of preventing regurgitation of gastric contents when correctly applied. A force of 30 N (3 kg) is recommended for an unconscious patient. This study assesses the validity of using floor scales to measure cricoid force applied by anaesthetic assistants and compares their use to an established training technique. Forty subjects applied pressure to a cricoid model in a blinded manner, on three test occasions. For each test, cricoid pressure was maintained for 1 min and the highest and lowest forces recorded on the model were noted. The first test was before any instruction. The second test followed a period of practice on the cricoid model. For the final test, subjects stood upon a set of floor scales and noted their weight. Force was applied to the cricoid model until the weight on the floor scales reduced by 3 kg. Performance improved both following practice on the model and using the floor scales. Applying cricoid force while standing on floor scales and using the change in weight as a guide resulted in a predictable force on the cricoid model. The use of floor scales is a useful method of demonstrating the forces needed for effective cricoid pressure.
The effect of introducer gauge, design and bevel direction on the deflection of spinal needles*
Authors: Ahn W‐S. , Bahk J‐H. , Lim Y‐J. , Kim Y‐C.
Published: March 2003

This study was performed to determine how the use of an introducer affects the extent to which a needle deflects during a spinal or combined spinal‐epidural injection. A polystyrene block was used to simulate the paraspinal area of the back. A line was drawn perpendicular to the edge of the block to use as a guide and to measure the deflection. The use of an introducer needle decreased the deflection in all the bevelled needles (p < 0.001). Depending on the direction of both the bevels, the deflection decreased as the introducer bevel was changed from the same direction, to right‐angles to bevel direction and then to a direction opposite to that of the spinal needle (p < 0.05). Deflection was decreased when a thick introducer was used (p < 0.001). The use of an introducer increased the deflection of the pencil‐point needle only in the deflection direction of the introducer (p < 0.001). The 18‐gauge Tuohy needle with a ‘backhole’ deflected more than the corresponding needle without a backhole (p < 0.001), and the spinal needle inserted through the Tuohy needle with a backhole deflected more (p = 0.002). Besides the tip type and gauge, the deflection of a spinal needle depends upon the use of introducer, its gauge and bevel direction. The deflection of a Tuohy needle depends upon its design, gauge and the presence of a backhole.