bluuebunny/crossref_metadata_2025 huggingface dataset:
The recognition of critical incidents: quantification of monitor effectiveness
Authors: Findlay G. P. , Spittal M. J. , Radcliffe J. J.
Published: March 2003

We have conducted a prospective analysis of all reported critical incidents which occurred during the period from admission to the anaesthetic room until discharge from the operating theatre complex over a 1‐year period. The aim was to identify which monitors were most effective for initial recognition of those incidents. All patients were monitored in accordance with the recommendations of the Association of Anaesthetists of Great Britain and Ireland. Five thousand and fifty‐six anaesthetic procedures gave rise to 338 recorded critical incidents, of which 27 were deemed to have caused, or been likely to cause, patient harm. We have shown that a combination of arterial blood pressure measurement (noninvasive), ECG, pulse oximetry and clinical observation detected 90% of all reported critical incidents, and all the incidents causing patient harm. We have also shown that blood pressure monitoring by itself, and combined with ECG and pulse oximetry, detected proportionately more critical incidents resulting in patient harm (incidents resulting in harm/remaining incidents, for each monitor) than clinical observation alone (p < 0.05) and all other remaining forms of monitoring together (p < 0.01).
Peribulbar anaesthesia using a mixture of local anaesthetic and vecuronium
Authors: Reah G. , Bodenham A. R. , Braithwaite P. , Esmond J. , Menage M. J.
Published: March 2003

The aim of this double‐blind, randomised study was to assess the effects of the addition of 0.5 mg of vecuronium bromide to a standard local anaesthetic mixture used for peribulbar anaesthesia. We studied 60 patients undergoing regional anaesthesia for intra‐ocular surgery and were primarily interested in the quality of globe and lid akinesia. All received a mixture of 5 ml 2% lignocaine with 1:200 000 adrenaline, 5 ml 0.75% bupivacaine and 150 IU hyaluronidase with either 0.9% saline 0.25 ml (group A, n = 30) or vecuronium bromide 0.25 ml (0.5 mg) (group B, n = 30). Eye movements assessed at both 5 and 10 min were significantly reduced in the vecuronium group (group B) (p < 0.05). We conclude that the addition of vecuronium at a dose of 0.5 mg to the standard local anaesthetic mixture improves the quality of globe and lid akinesia.
Closed‐loop controlled administration of propofol using bispectral analysis
Authors: Mortier E. , Struys M. , De Smet T. , Versichelen L. , Rolly G.
Published: March 2003

Ten patients, undergoing elective orthopaedic surgery under spinal anaesthesia, were sedated with propofol using a closed‐loop feedback control system. The bispectral index (BIS), a new processed EEG parameter, was used as control variable. Propofol administration was controlled by a patient individualised adaptive model‐based controller incorporating target‐controlled infusion technology combined with a pharmacokinetic‐dynamic model. This feedback control system for propofol administration proved to be adequate and safe. BIS was found to be well suited as control variable.
Serum albumin and colloid osmotic pressure in survivors and nonsurvivors of prolonged critical illness
Authors: Blunt M. C. , Nicholson J. P. , Park G. R.
Published: March 2003

We retrospectively compared the changes in serum albumin concentration and colloid osmotic pressure between survivors and nonsurvivors of prolonged (≥7 days) critical illness over a 2‐year period from 1 July 1995. All patients had serum albumin measured daily, and colloid osmotic pressure measured 5 days a week, throughout their ICU admission. They received crystalloid and colloid infusions as well as parenteral or enteral feeding. Infusions of albumin were not used to treat hypoalbuminaemia. One hundred and forty‐five patients were included, 66 nonsurvivors and 79 survivors. Nonsurvivors were significantly older than survivors [mean (95% CI): 58 (3.8) and 49 (4.1) years, respectively] and had a greater risk of death [mean (95% CI): 0.44 (0.06) and 0.28 (0.05); p < 0.05]. There was no significant difference in gender, APACHE II score [mean (95% CI): 22 (2.7) (nonsurvivors); 18 (2.3) (survivors)] or length of stay [median (interquartile range): 14 (9–27) days (nonsurvivors); 15 (9–26) days (survivors)]. There was no difference between the two groups in the absolute minimum serum albumin concentrations reached, the time to reach that minimum or the minimum in the first 7 days. However, nonsurvivors had a significantly lower mean serum albumin concentration: [mean (95% CI): 15.7 (5.1) gl−1 compared with 18.3 (4.6) gl−1 in survivors; p < 0.05]. They also had a lower recovery mean (the weighted mean after the minimum value): [mean (95% CI): 13.3 (5.1) gl−1 (nonsurvivors) and 18.6 (5.3) gl−1 (survivors); p < 0.01]. Analysis of colloid osmotic pressure results showed no difference between the groups in mean, minimum or recovery mean. Regression analysis of mean colloid osmotic pressure and albumin revealed that albumin only contributed 17% of the colloid osmotic pressure in these patients. The similar decrease in albumin in nonsurvivors and survivors may reflect the acute inflammatory response and/or haemodilution. However, survivors showed an ability to increase serum albumin concentrations, possibly owing to resumption of synthesis. The colloid osmotic pressure varied little between or within either group of patients, possibly because of the use of artificial colloids. There was no relationship between death and colloid osmotic pressure.
Parental anxiety before elective surgery in children A British perspective
Authors: Shirley P. J. , Thompson N. , Kenward M. , Johnston G.
Published: March 2003

This study measures the anxiety levels in 100 parents of children scheduled for elective surgery at the Royal Aberdeen Children's Hospital. Anxiety levels were quantified using the Leeds scale for self‐assessment of anxiety. Forty‐two per cent of parents were significantly anxious. Mothers were identified as being more pathologically anxious than fathers. The ‘anxious’ parents were specifically more anxious about the surgery, anaesthesia, postoperative pain and treatment, and hospitalisation in general. All parents, whether identified as anxious or not, agreed on factors likely to reduce anxiety: pre‐operative information from staff, being able to accompany their child to the operating theatre and being present at induction of anaesthesia.
APACHE II, data accuracy and outcome prediction
Authors: Goldhill D. R. , Sumner A.
Published: March 2003

From review of 122 intensive care charts, Acute Physiology and Chronic Health Evaluation (APACHE) II points were determined for eight physiological values. Using a strict interpretation of APACHE II criteria, an average of 20.6% of these points were higher and 6.7% lower than the points entered originally into an intensive care database. The resulting 1.73 points mean increase in APACHE II score increased predicted mortality from 24.8% to 27.8% and decreased the mortality ratio (observed hospital deaths ÷ predicted deaths) from 1.52 (95% confidence interval: 1.11–2.03) to 1.35 (95% confidence interval: 0.99–1.81). There were few errors entering the data recorded on the audit form into the intensive care unit database with an optical mark reader and keyboard. Inaccuracy and inconsistency in data collection must be excluded before differences in mortality ratios are ascribed to intensive care unit performance.
Multiple‐choice examinations: adopting an evidence‐based approach to exam technique
Authors: Hammond E. J. , McIndoe A. K. , Sansome A. J. , Spargo P. M.
Published: March 2003

Negatively marked multiple‐choice questions (MCQs) are part of the assessment process in both the Primary and Final examinations for the fellowship of the Royal College of Anaesthetists. It is said that candidates who guess will lose marks in the MCQ paper. We studied candidates attending a pre‐examination revision course and have shown that an evaluation of examination technique is an important part of an individual's preparation. All candidates benefited substantially from backing their educated guesses while only 3 out of 27 lost marks from backing their wild guesses. Failure to appreciate the relationship between knowledge and technique may significantly affect a candidate's performance in the examination.
Retracted: Prophylactic anti‐emetic therapy with granisetron, droperidol and metoclopramide in female patients undergoing middle ear surgery
Authors: Fujii Y. , Toyooka H. , Tanaka H.
Published: March 2003

The efficacy of granisetron, droperidol and metoclopramide for the prevention of postoperative nausea and vomiting in female patients undergoing middle ear surgery was compared. In a randomised, double‐blind study, 180 patients received granisetron 40 μg.kg−1, droperidol 20 μg.kg−1 or metoclopramide 0.2 mg.kg−1 given intravenously immediately before induction of anaesthesia (n = 60 for each). A standardised general anaesthetic technique was employed throughout. A complete response, defined as no postoperative nausea and vomiting and no need for another rescue anti‐emetic, during the first 3 h after anaesthesia was achieved in 83%, 58% and 55% of patients who had received granisetron, droperidol and metoclopramide, respectively. The corresponding incidence during the next 21 h after anaesthesia was 85%, 54% and 47% (p < 0.05). No clinically important adverse effects were observed in any of the groups. We conclude that prophylactic therapy with granisetron is superior to droperidol or metoclopramide in the prevention of postoperative nausea and vomiting after middle ear surgery.
Anatomical variation of cerebral venous drainage: the theoretical effect on jugular bulb blood samples
Authors: C Beards S. , Yule S. , Kassner A. , Jackson A.
Published: March 2003

Recent studies have demonstrated significant variation in bilateral jugular venous oxygen saturation measurements which may be of clinical significance. We have therefore measured variations in normal dural sinus venous drainage to assess the possible effects of normal anatomical variations on measured jugular venous oxygen saturation. Normal volunteers (n = 25) were imaged using magnetic resonance venography to demonstrate variations in venous anatomy. Flow was measured in the superior sagittal sinus and bilaterally in the transverse sinus, sigmoid sinus proximal to the jugular bulb and proximal jugular vein using phase difference magnetic resonance imaging. Examination of magnetic resonance venogram images showed considerable variability in the symmetry of transverse sinus flow. Complete absence of one transverse sinus was seen in four cases and significant asymmetry in the size of the transverse sinuses was present in 13. Quantitative flow studies demonstrated that the ratio of superior sagittal sinus to combined jugular bulb flow showed remarkably little variation (0.46 ± 0.06). Measurements of transverse sinus flow showed significant asymmetry (< 40% of superior sagittal sinus flow in one transverse sinus) in 21 of 25 volunteers. The effect of the observed asymmetry on jugular venous oxygen saturation was modelled based on the assumption of either a supratentorial or infratentorial lesion. This model predicted significant asymmetry in jugular venous oxygen saturation measurements (> 10%) in 65% of cases with a supratentorial lesion which is in close agreement with clinical observations. This study suggests that normal variations in venous drainage may account for observed asymmetry in jugular venous oxygen saturation measurements.
Surgical face masks and downward dispersal of bacteria
Authors: McLure H. A. , Talboys C. A. , Yentis S. M. , Azadian B. S.
Published: March 2003

The ability of face masks to prevent forward dispersal of bacteria is offset by the possibility that they may increase vertical shedding of bacteria from the face during facial movement. To investigate this, a blood agar plate was placed 30 cm directly below the lips of 20 volunteers who were encouraged to talk for 20 min while moving their heads from side to side, without a face mask for the first 5 min and then with a standard, soft pleated face mask for the subsequent 15 min. The agar plates were changed at 5‐min intervals. Analysis of the number of bacterial colonies grown on each agar plate showed a statistically significant reduction in the median number of colonies cultured per plate when the mask was worn. Our results suggest that for procedures lasting less than 15 min, the operator should wear a face mask, particularly when the face is in close proximity to the operative field and the need for speaking is anticipated.
An unexpected complication of the intubating laryngeal mask
Authors: Branthwaite M. A.
Published: March 2003

Fatal oesophageal perforation occurred as a complication of elective general anaesthesia for cataract extraction in a 77‐year‐old female patient. Tracheal intubation had been achieved, albeit with difficulty, in the course of a clinical trial of the intubating laryngeal mask.
Choice of cuff inflation medium during nitrous oxide anaesthesia
Authors: Mitchell V. , Adams T. , Calder I.
Published: March 2003

Air, saline and a mixture of nitrous oxide and oxygen were used to inflate the cuffs of tracheal tubes inserted into three groups of patients, during nitrous oxide anaesthesia. Large increases in intracuff pressure were seen in the air group, but no morbidity resulted. The intracuff pressure decreased in the gas mix group and leaks occurred in some patients. Initial adjustment of cuff pressure was more difficult in the saline group but the pressure remained stable thereafter.
Hygienic practices of consultant anaesthetists: a survey in the North‐West region of the UK
Authors: El Mikatti N. , Dillon P. , Healy T. E. J.
Published: March 2003

Questionnaires were distributed to all 213 consultant anaesthetists in the North‐West region of the UK with a response rate of 68%. These questionnaires were designed to assess the hygienic precautions taken to reduce the potential for transmission of infectious agents to and from the patients under their care. Face masks and gloves were always used by 35.2% and 14.5%, respectively, while only 36.4% washed their hands between cases. Most respondents have changed their practice since the recognition of HIV transmission (74.8%) and hepatitis B and C (69.8%). A high proportion of anaesthetists continue to administer anaesthesia despite suffering from respiratory (94%), gastrointestinal (42.9%) or herpes simplex (32.6%) infections. The anaesthetic breathing system was changed at the end of each day or following a high‐risk case by 33.3% of the respondents, while just over 25% changed it following a known infected case. Bacterial filters were used by 17% and changed after each case by 7.2%. On a scale of 0–10 (10 = significant) anaesthetists rated their potential for transmitting or contributing to patient infection as a median of 3 (interquartile range: 2–6). The results of this study show that, although anaesthetists are well aware of proper hygienic practices, their performance falls short of accepted recommendations.
Peri‐operative silent myocardial ischaemia in patients undergoing lower limb joint replacement surgery: an indicator of postoperative morbidity or mortality?
Authors: French G. W. G. , Lam W. H. , Rashid Z. , Sear J. W. , Foëx P. , Howell S.
Published: March 2003

One hundred and twenty‐seven patients undergoing major lower limb joint replacement surgery were studied to determine the incidence of silent myocardial ischaemia and to ascertain any link between pre‐operative cardiac risk factors, silent myocardial ischaemia and postoperative morbidity. Patients underwent ambulatory ECG monitoring for 4 days (on the pre‐operative night and for 3 days postoperatively). Postoperative cardiorespiratory symptomatology and morbidity was assessed by questionnaire at 3 months. Eighty‐seven patients had risk factors for silent myocardial ischaemia; 42 patients (30 with risk factors) had peri‐operative silent myocardial ischaemia. The median ischaemic loads (range) were 1.04 (0.32–13.31) min.h−1 pre‐operatively and 5.53 (0.26–56.39), 6.69 (0.04–42.71) and 1.23 (0.1–53.74) min.h−1 on postoperative days 1–3, respectively. Risk factors did not predict the occurrence of silent myocardial ischaemia or an increased ischaemic load pre‐operatively or overall postoperatively. New symptoms (chest pain, palpitations, breathlessness or fatigue) were associated with both silent myocardial ischaemia and ischaemic load (p < 0.05). Thus cardiac risk factors do not predict the occurrence of silent myocardial ischaemia or adverse outcome. Peri‐operative silent myocardial ischaemia was associated with increased postoperative fatigue.
Life‐threatening airway obstruction caused by a retropharyngeal haematoma
Authors: Senthuran S. , Lim S. , Gunning K. E.
Published: March 2003

We present the case of a 68‐year‐old woman who had a large cervicomediastinal haematoma that caused life‐threatening airway obstruction. Retropharyngeal haematoma may occur in any age group and following a variety of causes. Retropharyngeal haematomas must be considered as a cause of airway obstruction following common injuries such as blunt cervical trauma or internal jugular vein cannulation. A high index of suspicion and early lateral neck X‐ray is essential for safe management of this rare but potentially life‐threatening injury.
Time course of changes in breathing pattern in morphine‐ and oxycodone‐induced respiratory depression
Authors: Leino  , Mildh  , Lertola  , Seppälä  , Kirvelä
Published: March 2003

The time course of changes in breathing pattern in opioid‐induced respiratory depression was characterised for two opioids. Intravenous morphine (0.039 mg.kg−1 bolus + 0.215 mg.kg−1.h−1 infusion) and oxycodone (0.05 mg.kg−1 bolus + 0.275 mg.kg−1.h−1 infusion) were administered to six healthy male volunteers for 2 h in a random, double‐blind and cross‐over fashion. Monitoring included pulse oximetry and noninvasive respiratory‐inductive plethysmography for the measurement of breathing pattern. The total amounts of drugs given were 35.1 (0.0) mg [mean (SD)] morphine and 41.3 (8.0) mg oxycodone. Four of the six oxycodone infusions had to be stopped at 99 (14) min because of respiratory depression as judged by pulse oximetry. No morphine infusions were stopped. The first changes in breathing pattern were a decrease in respiratory rate and an increase in the contribution of the rib cage to tidal volume, while the compensatory increase in tidal volume became evident later. A decrease in minute ventilation and inspiratory duty cycle were also found.
The effect of steam sterilisation at 134 °C on light intensity provided by fibrelight Macintosh laryngoscopes
Authors: Bucx  , Veldman  , Beenhakker  , Koster
Published: March 2003

We studied the repeated effect of sterilisation on light intensity in laryngoscopes from Penlon, Riester, Heine (two different blades), Medicon and Upsher. Light intensity was measured by a light meter using two methods. Measurements were performed before the decontamination procedure was carried out and subsequently after each series of 25 procedures until a total of 200 cycles was reached. Using method 1 (and 2), the reduction in light intensity after 200 cycles was 100% (100%; no light emitted), 37% (13%), 75% (69%), 79% (60%), 37% (14%) and 63% (55%) for each blade, respectively.
The patient‐at‐risk team: identifying and managing seriously ill ward patients
Authors: Goldhill  , Worthington  , Mulcahy  , Tarling  , Sumner
Published: March 2003

A ‘patient‐at‐risk team’, established to allow the early identification of seriously ill patients on hospital wards, made 69 assessments on 63 patients over 6 months. Predefined physiological criteria were not able to reliably predict which patients would be admitted to the intensive care unit. The incidence of cardiopulmonary resuscitation before intensive care admission was 3.6% for patients seen by the team and 30.4% for those not seen (p < 0.005). Of admissions seen by the team, 25% died on the intensive care unit compared with 45% of those not seen (not significant, p = 0.07). Among those not seen by the team, mortality was 40% for those who did not require resuscitation and 57% for those who did (not significant). Many critically ill ward patients had abnormal physiological values before intensive care unit admission. Identification of critically ill patients on the ward and early advice and active management are likely to prevent the need for cardiopulmonary resuscitation and to improve outcome.
Anaesthetic management of Caesarean section in an elderly parturient with pre‐eclampsia
Authors: Nesbitt  , Bythell  , Redfern
Published: March 2003

The number of women over 40 years of age becoming pregnant has increased over recent years. They suffer a high incidence of hypertensive complications, and require more frequent operative interventions. We present a case report of a 51‐year‐old woman having a Caesarean section for a twin pregnancy complicated by pre‐eclampsia. We discuss the effects of age on pregnancy and the implications for anaesthetic management.
The effects of ropivacaine hydrochloride on coagulation and fibrinolysisAn assessment using thromboelastography
Authors: Porter  , McGinley  , O'Hare  , Shorten
Published: March 2003

Amide local anaesthetics impair coagulation by inhibition of platelet function and enhanced fibrinolysis. The potential therefore exists that the presence of amide local anaesthetics in the epidural space could contribute to the therapeutic failure of an epidural autologous blood patch. Ropivacaine is an aminoamide local anaesthetic increasingly used for epidural analgesia and anaesthesia, particularly in obstetric practice. This study was undertaken to investigate whether concentrations of ropivacaine in blood, which could occur clinically in the epidural space, alter coagulation or fibrinolysis. Thromboelastography was used to assess clotting and fibrinolysis of blood to which ropivacaine had been added. Although modest alterations in maximum amplitude, coagulation time and alpha angle were observed, the effect of ropivacaine on clotting and fibrinolysis was not clinically significant. We conclude that it is unlikely that the presence of ropivacaine in the epidural space would reduce the efficacy of an early or prophylactic epidural blood patch.
Adrenocortical function in critically ill patients 24 h after a single dose of etomidate
Authors: Absalom  , Pledger  , Kong
Published: March 2003

We compared the effects of single doses of etomidate and thiopentone on adrenocortical function in a randomised controlled clinical trial involving 35 critically ill patients who needed a general anaesthetic. Just before induction of anaesthesia, a baseline blood cortisol sample was taken. Twenty‐four hours later we performed a short adrenocorticotrophic hormone stimulation test. No patient had a low cortisol level (< 160 nmol.l−1) at any time during the study. Baseline, pre‐ACTH and post‐ACTH cortisol levels were similar in the two groups. However, significantly more patients in the etomidate group had an ACTH‐stimulated cortisol increment < 200 nmol.l−1. The clinical significance of these findings is not clear, but we conclude that single doses of etomidate may interfere with cortisol synthesis for at least 24 h in the critically ill.
Delayed pneumothorax and hydrothorax with central venous catheter migration
Authors: Thomas C. J. , Butler C. S.
Published: March 2003

We report a case of delayed pneumothorax, central venous catheter migration and iatrogenic hydrothorax in a 22‐year‐old female. The left subclavian central venous catheter initially transfixed the lung apex; pneumothorax occurred 24 h later following initiation of positive pressure ventilation. Lung collapse as a result of the pneumothorax caused catheter migration and hydrothorax. Catheter removal and chest drainage led to an uneventful recovery.
THIS ARTICLE HAS BEEN RETRACTED: Relationship between stimulating current and accelographic train‐of‐four response at the great toe
Authors: Saitoh Y. , Narumi Y. , Fujii Y. , Ueki M.
Published: March 2003

We investigated the accelographic train‐of‐four response evaluated at the great toe at varying stimulating currents. Fifteen adult patients undergoing elective general anaesthesia were studied. The mean current at which a supramaximal T1 value could be elicited was > 49 (9) mA [mean (SD)]. Ratios of accelographic T1 values at 50, 40, 30, 20 and 10 mA to accelographic T1 value at 60 mA were 0.90 (0.18), 0.58 (0.37), 0.38 (0.37), 0.19 (0.26) and 0.00 (0.00), respectively [mean (SD), p < 0.05 for 50 mA vs. 30, 20 and 10 mA, p < 0.05 for 40 mA vs. 20 and 10 mA, and p < 0.05 for 30 vs. 10 mA]. Threshold currents for train‐of‐four (the lowest currents at which any train‐of‐four response could be elicited) before and after induction of anaesthesia were 30 (10) and 31 (10) mA, respectively. The train‐of‐four ratio (T4/T1) measured at varying currents did not differ significantly. However, in the patients in whom threshold currents for train‐of‐four were 40, 30 and 20 mA, the train‐of‐four ratio recorded at the threshold current was significantly less than at 50 mA. We conclude that at the great toe, the mean current at which a supramaximal response to train‐of‐four can be yielded is as high as > 49 mA. The mean threshold currents for TOF before and after induction of anaesthesia were 30 and 31 mA, respectively. Train‐of‐four ratio measured at the threshold current is less than that at 50 mA.
Personality traits of anaesthetists and physicians: an evaluation using the Cloninger Temperament and Character Inventory (TCI‐125)
Authors: Kluger M. T. , Laidlaw T. M. , Kruger N. , Harrison M. J.
Published: March 2003

The personality profiles of Specialist Anaesthetists, Trainee Anaesthetists and Specialist Physicians were examined using Cloninger's Temperament and Character Inventory. These were compared with validated Community Sample ‘average values’ and a historical Norwegian Physician sample. Completed forms were returned from 364 doctors (Specialist Anaesthetists 222, Trainee Anaesthetists 75, Physicians 67), an overall response rate of 71%. Specialist Anaesthetists were more Cooperative, Harm Avoidant and Self‐Directed than the Community Sample but less Reward Dependent, Novelty Seeking and Persistent than the Community Sample. Physicians were more Cooperative than their Specialist Anaesthetist colleagues, but both more so than were the general population. Trainee anaesthetists appear to be more Novelty Seeking and Reward Dependent than the Specialist Anaesthetists, this factor being predominately age related. Extreme/Mild personality traits were identified in 33% of Specialists, 41% of Trainees and 33% of Physicians, whilst personality disorders were found at the expected rates (Specialist Anaesthetists 9%, Trainee Anaesthetists 10%, Physicians 2%). Personality assessment has implications for recruitment, crisis management and professional development within anaesthesia.
Upper airway reflex sensitivity following general anaesthesia for day‐case surgery
Authors: Caranza R. , Nandwani N. , Tring J. P. , Thompson J. P. , Smith G.
Published: March 2003

We have studied changes in upper airway reflex sensitivity following general anaesthesia using dilute ammonia vapour as a chemical stimulant in 16 patients undergoing elective laparoscopic gynaecological surgery. We measured the threshold concentration of ammonia vapour required to elicit a transient reduction of inspiratory flow caused by glottic closure, defined as a glottic stop. Measurements of upper airway reflex sensitivity and auditory reaction time were obtained before surgery, and at 60 and 120 min after recovery. Auditory reaction time was depressed significantly at 60 min but was similar to baseline values 120 min after recovery. Upper airway reflex sensitivity remained significantly reduced at 60 and 120 min despite the return of auditory reaction time to normal. The lack of correlation between upper airway reflex sensitivity and auditory reaction time suggests that central nervous system depression alone does not explain the delayed recovery in airway reactivity.
An independent assessment of a supraregional pain management programme and comparison of patients' and general practitioners' perceptions of the effects
Authors: Gupta S. , Francis J. D. , Porter G. E. , Valentine J. M. J.
Published: March 2003

This study was designed to evaluate the therapeutic response, as perceived by patients and their general practitioners, to a supraregional residential pain management programme (INPUT). Twenty patients who completed the INPUT programme and their general practitioners, were sent locally designed questionnaires. Eighteen patients and 16 general practitioners responded. Patients were assessed for the effects of the programme on a wide variety of treatment targets reflecting quality of life. General practitioners were questioned about changes in dependence upon healthcare services. The mean time from attending INPUT to assessment was 11.4 (5.7) months. Thirteen patients indicated a moderate or maximal improvement in quality of life. General practitioners reported a reduced use of healthcare services and improvement in quality of life. The majority of our patients attending INPUT gained benefits that improved their quality of life. Healthcare services appeared to benefit from the patients' greater independence in managing their symptoms.
Performance of the Radiometer OSM3 and ABL505 blood gas analysers for determination of sodium, potassium and haemoglobin concentrations
Authors: King R. , Campbell A.
Published: March 2003

We have compared results obtained from two widely used ward‐based blood gas analysers, the Radiometer OSM3 and ABL505, with standard laboratory analysers, for haemoglobin, sodium and potassium measurement in critically ill adult patients. During the study, paired samples for analysis were obtained from 81 patients for haemoglobin, 115 patients for sodium and 95 patients for potassium. There was good agreement between the ward and the laboratory analysers in terms of the mean results for each test. However, the limits of agreement for the ward‐based analysers were wide, suggesting that their results should be used with caution.
Laser surgery in a patient with Romano‐Ward (long QT) syndrome and an automatic implantable cardioverter defibrillator
Authors: Lloyd Jones S. , Mason R. A.
Published: March 2003

A 48‐year‐old woman with Romano–Ward syndrome (a hereditary long QT syndrome), asthma and an automatic implantable cardioverter defibrillator presented for laser surgery for debulking of a massive nasopharyngeal tumour prior to radiotherapy. Automatic implantable cardioverter defibrillators have only relatively recently been used to treat patients with the long QT syndrome and are indicated for the high‐risk individual when conventional treatment has failed or when beta‐blockers are contraindicated. If surgery requires the use of surgical diathermy, a cardiac technician must be present to deactivate the defibrillator and external pacing electrodes are sited on the chest until the defibrillator can be reactivated. Radiotherapy requires both deactivation and shielding of the device.
Effect of ephedrine on auditory‐evoked potentials during light general anaesthesia
Authors: Mori M. , Yamamoto H. , Hattori S. , Miyakawa H. , Noguchi T.
Published: March 2003

Ephedrine, a sympathomimetic drug, may stimulate the central nervous system via its amphetamine‐like effect under light general anaesthesia. We compared the effect of ephedrine on auditory‐evoked potentials with that of etilefrine, a sympathomimetic drug that lacks an amphetamine‐like effect, in patients undergoing abdominal surgery under general anaesthesia with 67% nitrous oxide in oxygen and epidural blockade. Ephedrine (0.08 mg.kg−1 intravenously) significantly decreased the latencies of Nb and P1 from 49.5 (4.2) [mean (SD)] and 63.9 (9.1) ms to 45.9 (4.2) and 59.0 (9.9) ms, respectively; whereas etilefrine (0.02 mg.kg−1 intravenously) caused no significant changes in these potentials. In addition, the latencies of Nb and P1 before drug administration were positively correlated with patient age. These findings suggest that ephedrine can cause excitation of the central nervous system during light general anaesthesia, and that auditory‐evoked potentials may be a sensitive indicator of the depth of anaesthesia.
A new practical classification of laryngeal view
Authors: Cook T. M.
Published: March 2003

A new practical classification of laryngeal view at laryngoscopy is presented and evaluated. The best laryngeal view obtained with or without anterior laryngeal pressure is recorded. The laryngeal view is easy (E)when the laryngeal inlet is visible. The view is restricted (R) when the posterior glottic structures (posterior commissure or arytenoids) are visible or the epiglottis is visible and can be lifted; this includes some grade 2 and some grade 3 views as classified by Cormack and Lehane. A difficult (D) view is present when the epiglottis cannot be lifted or when no laryngeal structures are visible. Five hundred patients were studied. Laryngoscopy, with the patient anaesthetised and paralysed, was performed with a Macintosh laryngoscope. If the vocal cords were not visible, a gum elastic bougie was used to aid intubation. Other aids were used only if this did not allow intubation. Each laryngeal view was graded according to the new classification and that of Cormack and Lehane. Intubation was timed and the equipment needed to facilitate intubation was recorded. The new classification stratified increasing difficulty with intubation (time for intubation longer and increasingly complex methods needed) better than the Cormack and Lehane classification. The new classification is as sensitive and more specific than the Cormack and Lehane classification in predicting difficult intubation. It is also more sensitive and more specific in predicting easy intubation.
Haemodynamic changes during laparoscopic anterior fundoplication measured by trans‐oesophageal Doppler ultrasound
Authors: Dickson R. E. , Robertson E. A. , Krukowski Z. H.
Published: March 2003

We investigated the cardiovascular effects of pneumoperitoneum and steep head‐up tilt during laparoscopic fundoplication using an intra‐oesophageal Doppler ultrasound probe. Repositioning of the probe proved sufficient to maintain the signal throughout the procedure despite the pneumomediastinum. There was a statistically significant increase in mean arterial blood pressure and a fall in stroke distance but not in systemic vascular resistance. Increasing or decreasing the blood pressure with drugs improved stroke distance. The oesophageal Doppler ultrasound proved a satisfactory method for assessing cardiovascular changes during fundoplication.
Alteration in flow delivery with antisyphon devices
Authors: McCarroll C. , McAtamney D. , Taylor R.
Published: March 2003

The aim of this study was to determine whether infusion sets containing antisyphon devices increased the time to initial flow from syringe drivers. The antisyphon devices assessed were those manufactured by B Braun, Wescott and Vygon. Each device was placed between a 50‐ml syringe and a spiral extension set and primed with saline. A fourth syringe and spiral extension set acted as a control. The infusion sets were placed in four identical syringe drivers and started simultaneously. The time from pressing the start button until the initial flow for each infusion set (start‐up time) was recorded. The test was conducted 15 times each at 2 ml.h−1, 10 ml.h−1 and 50 ml.h−1. At 2 ml.h−1 the start‐up time was significantly longer with all the antisyphon sets compared with the control (p < 0.0001). At higher infusion rates the differences between the antisyphon sets and the control were less pronounced. Clinicians who use syringe driver infusions should be aware of this delay between the activation of the infusion pump and the onset of flow and take steps to prevent it.
An assessment of the thermal safety of microwave warming of crystalloid fluids
Authors: Lindhoff G. A. , MacG. Palmer J. H.
Published: March 2003

We performed an in vitro study to determine the thermal safety of a domestic microwave to warm intravenous crystalloid solutions. Five‐hundred‐millilitre bags of crystalloid, randomly allocated to groups which differed in power setting, timer setting and whether or not agitation was performed after warming, were heated in a microwave oven to a calculated temperature of 39 °C. Timer accuracy was checked by stopwatch. Bag temperature was measured using an infrared tympanic temperature probe and fluid temperature was measured with an in‐line thermocouple. Mean times measured by stopwatch were higher than set. No in‐line temperatures reached 40 °C. Wider overall ranges and a higher mean were found with the tympanic probe compared with in‐line temperature measurement. There were significant differences between the in‐line temperatures of shaken and unshaken bags at each power setting, but not when groups were added together. There was no change in colour or odour of bags or fluid. One bag developed a pinhole leak when the packaging was removed.
A modified Guedel airway for continuous oxygenation and suctioning during fibreoptic bronchoscopy
Authors: Ayoub C. , Itani M. M. , Lteif A. , Baraka A.
Published: March 2003

We describe a modification to the Guedel airway that improves suction and oxygenation during fibreoptic bronchoscopy. The entire roof of a Guedel airway was removed. Two 2.5‐mm internal diameter tracheal tubes were inserted into the modified airway to allow continuous oxygen delivery and suction throughout fibreoptic bronchoscopy. It was tested as a single‐use device in ten patients undergoing awake fibreoptic bronchoscopy under sedation and topical anasthesia. During the procedure there were no problems with either fogging of the lens or secretions in the pharynx. In addition, oxyhaemoglobin saturation, as monitored continuously by pulse oximetry, was ≥ 97% in all patients.
Microbial contamination of gum elastic bougies
Authors: Cupitt J. M.
Published: March 2003

The gum elastic bougie is a simple device that is used to assist in the management of the difficult intubation. It is not uncommon for a bougie to be re‐used many times. This study investigated the incidence of microbial contamination of the bougies in one hospital. Potentially pathogenic organisms were identified both on the bougies and in their storage containers. This has implications for their cleaning and maintenance, and raises the question as to whether we should replace them with single‐use, disposable devices.
A protocol for safe anasthesia for cleft lip and palate surgery in developing countries
Authors: Hodges S. C. , Hodges A. M.
Published: March 2003

A project to perform surgical correction of cleft lips and palates was carried out in Uganda in 1998. Twenty centres were visited and 336 cleft lips and 41 cleft palates were repaired. The age of the patients ranged from 2 weeks to 60 years. Many of the centres visited were remote and lacked even the most basic equipment. Patients were anasthetised using ketamine, ether or halothane according to a protocol that we developed. There was no anasthetic mortality and only one case of significant morbidity. We report our experience and discuss recommendations regarding the provision of anasthesia in remote circumstances based on our outcome. An additional benefit of the project was that we provided training to local medical personnel in anasthesia and surgery for cleft lips and palates.
A survey of paediatric dental anaesthesia in Scotland*
Authors: Macmillan C. S. A. , Wildsmith J. A. W.
Published: March 2003

A postal survey of NHS hospital‐based anaesthetists providing out‐patient anaesthesia for dental procedures in children under 10 years of age was conducted in February 1999. Information was sought about quality of care and common practice in Scotland. The experience of the anaesthetists involved in such work was substantial, but the monitoring used did not meet current standards, with only 16% of respondents indicating use of a full range of standard devices. Separate recovery facilities were available to 99%, and all had access to a defibrillator, but the qualifications of dedicated assistant and recovery staff were lacking in 14 and 30%, respectively. Intravenous access was not obtained routinely after inhalational induction of anaesthesia by up to 71% (49%, never; 22%, sometimes). Systemic analgesia or local anaesthesia was used by 88%. Discharge times ranged from 10 min to 6 h.
Correlating obstetric epidural anaesthesia performance and psychomotor aptitude
Authors: Dashfield A. K. , Coghill J. C. , Langton J. A.
Published: March 2003

We investigated the correlation between the scores attained on computerised psychometric tests, measuring psychomotor and information processing aptitudes, and learning obstetric epidural anaesthesia. Ten anaesthetic trainees performed an adaptive tracking task (ADTRACK 3) and one information management task (MAZE) from the MICROPAT testing system. They then embarked on a standardised obstetric anaesthesia training programme prior to performing obstetric on‐call duties. The success or failure of their first 50 obstetric epidurals was recorded. There was a significant correlation between mean obstetric epidural failure rate for the second 25 consecutive epidurals and ADTRACK 3 (r = −0.579, p = 0.04) scores. The correlation between the means of the first 25 and 50 consecutive epidurals and ADTRACK 3 scores was not significant. There was no significant correlation between epidural failure rate and MAZE scores. The ratios of the mean epidural failure rate for the last 25 epidurals to the mean for the first 25 epidurals were not significantly correlated with ADTRACK 3 or MAZE scores. Psychomotor abilities appear to be poor determinants of trainees' initial proficiency at obstetric epidural anaesthesia or of trainees' rates of progress during early obstetric epidural training, but may be determinants of an individual's performance after the initial training phase.
The effect of humidification and smoking habit on the incidence of adverse airway events during deepening of anaesthesia with desflurane
Authors: Wilkes A. R. , Hall J. E. , Wright E. , Grundler S.
Published: March 2003

The effect of two levels of humidification on the incidence of adverse airway events was studied in 58 adult female patients during deepening of anaesthesia using up to 12% desflurane. Humidification was provided by a breathing system filter with either low moisture‐conserving performance (17.2 mg.l−1at 0.5 l tidal volume, Group L) or high moisture‐conserving performance (33.5 mg.l−1at 0.5 l tidal volume, Group H). Forty‐eight per cent of patients smoked and there were more smokers in Group L than in Group H. Adverse airway events consisted of coughing and laryngospasm. For coughing, the dominant explanator was smoking. When both humidity and age were included in the analysis, there was a significant smoking–humidity interaction (p < 0.05), such that high humidity decreased the incidence of coughing in nonsmokers but not in smokers. The incidence of laryngospasm was significantly lower in Group H than in Group L (p < 0.05). We conclude that when patients inspire high concentrations of desflurane during induction of anaesthesia, increasing humidification to the levels achieved in this study decreases the incidence of coughing among nonsmokers and of laryngospasm in both smokers and nonsmokers.
Hypoxia during upper gastrointestinal endoscopy with and without sedation and the effect of pre‐oxygenation on oxygen saturation
Authors: Wang C. Y. , Ling L. C. , Cardosa M. S. , Wong A. K. H. , Wong N. W.
Published: March 2003

In Study A, the incidence of arterial oxygen desaturation was studied using pulse oximetry (Sao2) in 100 sedated and 100 nonsedated patients breathing room air who underwent diagnostic upper gastrointestinal endoscopy. Hypoxia (Sao2 92% or less of at least 15 s duration) occurred in 17% and 6% of sedated patients and nonsedated patients, respectively (p < 0.03). Mild desaturation (Sao2 94% or less and less than 15 s duration) occurred in 47% of sedated patients compared with 12% of nonsedated patients (p < 0.001). In Study B, the effects of supplementary oxygen therapy and the effects of different pre‐oxygenation times on arterial oxygen saturation (Sao2) in sedated patients were studied using pulse oximetry. One hundred and twenty patients who underwent diagnostic upper gastrointestinal endoscopy with intravenous sedation were studied. Patients were randomly allocated to one of four groups: Group A (n = 30) received no supplementary oxygen while Groups B–D received supplementary oxygen at 4 l.min−1 via nasal cannulae. The pre‐oxygenation time in Group B (n = 30) was zero minutes, Group C (n = 30) was 2 min and Group D (n = 30) was 5 min before sedation and introduction of the endoscope. Hypoxia occurred in seven of the 30 patients in Group A and none in groups B, C and D (p < 0.001). We conclude that desaturation and hypoxia is common in patients undergoing upper gastrointestinal endoscopy with and without sedation. Sedation significantly increases the incidence of desaturation and hypoxia. Supplementary nasal oxygen at 4 l.min−1 in sedated patients abolishes desaturation and hypoxia. Pre‐oxygenation confers no additional benefit.
A comparison of antagonism of rocuronium‐induced neuromuscular blockade during sevoflurane and isoflurane anaesthesia
Authors: Sutcliffe D. G. , Murphy C. M. , Maslow A. , Uppington J. , Shorten G. D.
Published: March 2003

Volatile anaesthetic agents potentiate neuromuscular blocking agents and retard their rate of reversal. We hypothesised that there was a difference in the rate of reversal of rocuronium‐induced neuromuscular blockade based on the selection of inhalation agent. Thirty‐eight patients undergoing elective surgical procedures received either sevoflurane or isoflurane, by random allocation. Neuromuscular blockade was induced using rocuronium 0.6 mg.kg−1 followed by continuous intravenous infusion to maintain 90% suppression of the single twitch response. Upon completion of surgery, the rocuronium infusion was discontinued, neostigmine 50 µg.kg−1 and glycopyrrolate 10 µg.kg−1 were administered. Times from reversal to T1 = 25, 50 and 60% and train‐of‐four ratio = 0.6 were recorded. The mean (SD) times to train‐of‐four ratio = 0.6 in the isoflurane and sevoflurane groups were 327 (132) and 351 (127) s, respectively. The mean (SD) times to single twitch response T1 = 25, 50 and 60% in the isoflurane group were 81 (33), 161 (59) and 245 (84) s, respectively, and in the sevoflurane group were 95 (35), 203 (88) and 252 (127) s, respectively. It is concluded that reversal of rocuronium‐induced neuromuscular blockade is similar during isoflurane and sevoflurane anaesthesia.
Setting targets for sedation with a target‐controlled propofol infusion
Authors: Janzen P. R. M. , Hall W. J. , Hopkins P. M.
Published: March 2003

We studied 30 unpremedicated patients undergoing muscle biopsy under femoral nerve block to determine sedation levels reached with a Diprifusor® target‐controlled propofol infusion, in order to establish the equivalent of the ED50 for different levels of depth of sedation. Infusion was started at 0.8 µg.ml−1 and altered by increments of 0.1 µg.ml−1 after equilibrium between target and calculated concentrations, until the desired level of sedation was reached. The ED50 target propofol concentrations for sedation at sedation levels 2 (drowsy), 3 (drowsy, responds to verbal stimulation) and 4 (responsive to physical stimulation only) were 1.0 µg.ml−1, 1.6 µg.ml−1 and 2.1 µg.ml−1, respectively. At sedation level 3, several patients exhibited spontaneous movement, hindering surgery. Oxygen supplementation is recommended for sedation at level 4.