bluuebunny/crossref_metadata_2025 huggingface dataset:
Lipid‐induced colonic hypersensitivity in irritable bowel syndrome: the role of 5‐HT3 receptors
Authors: Simrén M. , Simms L. , D'Souza D. , Abrahamsson H. , Björnsson E. S.
Published: March 2003

Background : Irritable bowel syndrome patients demonstrate colonic hypersensitivity after duodenal lipid infusion.

Aim : To investigate the role of 5‐hydroxytryptamine‐3 (5‐HT3) receptors in this sensory component of the gastrocolonic response in irritable bowel syndrome.

Methods : Fifteen female patients with diarrhoea‐predominant irritable bowel syndrome completed a trial with the 5‐HT3 receptor antagonist alosetron (1 mg b.d.) or placebo (b.d.) over 15 days, followed by the alternative treatment. Each treatment period was followed by a colonic distension trial before and after duodenal lipids. Changes in colonic thresholds, tone and compliance and viscerosomatic referral pattern after lipids were compared between treatments.

Results : With placebo, the colonic thresholds after lipids were significantly reduced for all studied sensations, whereas, with alosetron, the thresholds were significantly reduced only for first sensation and discomfort, but not for gas and pain. The reductions in thresholds did not differ significantly between treatments, but the pain threshold after alosetron tended to be less reduced compared with placebo (P = 0.10). The effects of lipids on tone, compliance and viscerosomatic referral pattern were unaffected by alosetron relative to placebo.

Conclusions : 5‐HT3 receptor antagonism reduces the lipid‐induced colonic hypersensitivity in irritable bowel syndrome. However, 5‐HT3 receptors do not seem to be the principal mediator, but may be a cofactor for the exaggerated sensory component of the gastrocolonic response in irritable bowel syndrome.
Study of liver function in healthy elderly subjects using the 13C‐methacetin breath test
Authors: Ciccocioppo R. , Candelli M. , Di Francesco D. , Ciocca F. , Taglieri G. , Armuzzi A. , Gasbarrini G. , Gasbarrini A.
Published: March 2003

Background : The issue of whether or not liver function is compromised in the healthy elderly population remains unsolved.

Aim : To investigate the putative age‐related modifications of hepatic function using the 13C‐methacetin breath test. Because endogenous CO2 production changes with age, motor activity and nutrition, a different form of processing the results was investigated.

Patients and methods :
Twenty‐nine elderly subjects (mean age, 79.8 ± 7.9 years; female/male ratio, 17/12) and 28 adult subjects (mean age, 40.6 ± 12.3 years; female/male ratio, 13/15) underwent
13 C‐methacetin breath test and trans‐abdominal echosonography with Doppler pulsed wave analysis of the coeliac axis and portal vein.

Results : Although the 13CO2 peak occurred within 15–30 min in both elderly and adult subjects, it was significantly decreased in the former (30.66% ± 9.2% vs. 38.33% ± 6.05%; P < 0.001), as was the cumulative excretion (33.07% ± 7.06% vs. 39.81% ± 5.68%; P < 0.001). When correcting for the effects of CO2 excretion by age, the age‐related modification of the cumulative dose became more evident (elderly group 30.15% ± 6.46% vs. adult group 37.97% ± 5.92%; P < 0.0001). The elderly group also showed an increase in the intra‐hepatic resistance index using Doppler pulsed wave analysis, which inversely correlated with the results of the breath test.

Conclusions : Hepatic function is not well preserved in healthy humans throughout life and may be due to an increase in vascular resistance.
Retained common bile duct stones: a comparison between biliary stenting and complete clearance of stones by electrohydraulic lithotripsy
Authors: Hui C.‐K. , Lai K.‐C. , Ng M. , Wong W.‐M. , Yuen M.‐F. , Lam S.‐K. , Lai C.‐L. , Wong B.C.Y.
Published: March 2003

Background : There is some uncertainty as to whether high‐risk patients with difficult common bile duct stones should be subjected to a further endoscopic procedure for the complete removal of stones by electrohydraulic lithotripsy or whether permanent biliary stenting should be performed.

Aim : To compare the outcome of permanent biliary stenting with electrohydraulic lithotripsy in this group of patients.

Methods : In a prospective study, 36 patients with difficult common bile duct stones were investigated: 19 underwent double pigtail insertion (stent group), whereas 17 underwent complete clearance of stones (electrohydraulic lithotripsy).

Results : In the electrohydraulic lithotripsy group, successful stone clearance was achieved in 76.5%, whereas, in the stent group, the success of stenting was 94.7%. A significant difference was detected in the actuarial incidence of recurrent acute cholangitis when the electrohydraulic lithotripsy group was compared with the stent group [one patient (7.7%) vs. 12 patients (63.2%), respectively; P = 0.002, log rank test]. A significant difference was detected in the actuarial frequency of mortality between the electrohydraulic lithotripsy and stent groups [seven patients (41.2%) vs. 14 patients (73.7%), respectively; P = 0.01, log rank test].

Conclusions : The removal of difficult common bile duct stones by electrohydraulic lithotripsy and further endoscopic retrograde cholangiopancreatography has a high success rate and a low complication rate even in the elderly.
Symptomatic response to lansoprazole predicts abnormal acid reflux in endoscopy‐negative patients with non‐cardiac chest pain
Authors: Xia H. H. X. , Lai K. C. , Lam S. K. , Hu W. H. C. , Wong N. Y. H. , Hui W. M. , Lau C. P. , Chen W. H. , Chan C. K. , Wong W. M. , Wong B. C. Y.
Published: March 2003

Aim : To determine whether symptomatic response to lansoprazole predicts abnormal acid reflux in endoscopy‐negative patients with non‐cardiac chest pain.

Methods : Patients who complained of chest pain, but had normal coronary angiography, were asked to undergo upper endoscopy. Those without gastric and oesophageal lesions were recruited for 24‐h ambulatory oesophageal pH monitoring, and were randomly given lansoprazole 30 mg or placebo, both daily for 4 weeks. Chest pain symptoms were recorded before and 1 month after treatment on a locally validated questionnaire. The symptom score was calculated by multiplying the severity and frequency of the symptom, and symptom improvement was defined as > 50% reduction in symptom score.

Results : Overall, 68 patients, 36 on lansoprazole and 32 on placebo, completed the trial. The symptom score was reduced significantly in both groups (P < 0.001). In the lansoprazole group, more patients with than without abnormal reflux showed symptom improvement (92% vs. 33%; odds ratio = 22; 95% confidence interval, 2.3–201.8; χ2 = 10.9; P = 0.001), giving a sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 92%, 67%, 58%, 94% and 75%, respectively. In the placebo group, the rates of symptom improvement were similar between those with and without abnormal reflux (33% vs. 35%, P = N.S.).

Conclusions : Treatment with lansoprazole is a useful test in diagnosing endoscopy‐negative gastro‐oesophageal reflux disease in Chinese patients with non‐cardiac chest pain.
Use of unlicensed and off‐label medications in paediatric gastroenterology with a review of the commonly used formularies in the UK
Authors: Dick A. , Keady S. , Mohamed F. , Brayley S. , Thomson M. , Lloyd B. W. , Heuschkel R. , Afzal N. A.
Published: March 2003

Background : Use of unlicensed and off‐label medications is common in hospital based paediatric practice. Whilst inpatient prescription can be closely monitored within the hospital setting, it is subspecialties like paediatric gastroenterology, caring for chronically ill children on an outpatient basis that require administration of regular medications in the community. Local practitioners rely on available paediatric formularies or information provided by the tertiary unit for monitoring and dispensing further prescriptions.

Aim : To assess the proportion of unlicensed and off‐label medications prescribed in a paediatric gastroenterology unit to children discharged to the community and assess adequacy of information about these medications in commonly used British formularies.

Methods : All prescriptions prescribed over a six‐month period (Jan–Jul 2002) either in the paediatric gastroenterology outpatient department or for children discharged home after an inpatient stay, were retrieved from the pharmacy database. The main outcome measures were to assess the proportion of medications prescribed for unlicensed or off‐label use.

Results : 308 patients received 777 prescriptions of which 384 (49%) were for unlicensed or off‐label use. Of these 291 (76%) were off‐label; 208 in relation to indication and 83 to child's age. 93 of the prescribed medications were unlicensed; 37 were due to manipulation of formulation. Of the commonly used formularies in the UK, only ‘Medication for Children®’ contained dosage information on more than half (9/13) of the most often prescribed off‐label/unlicensed medications in paediatric gastroenterology.

Conclusions : Use of unlicensed and off‐label medications remains a problem in paediatric practice. Until licensing laws change and more drugs are licensed in children, paediatric gastroenterologists remain responsible for provision of information to families, local practitioners, nurses and pharmacists. Of the commonly used formularies, ‘Medicines for Children’ is the most detailed and comprehensive, and should be available to all general practitioners and pharmacists in the UK. Clear communication between specialist units and local practitioners is imperative to ensure safe and effective prescribing to children.
Sequential changes in gas exchange following traumatic fat embolism
Authors: Burnstein R. M. , Newell J. P. , Jones J. G.
Published: March 2003

We present a young man who developed fat embolism syndrome following a fractured femoral shaft. By intermittently measuring oxygen saturation with a pulse oximeter and varying the inspired partial pressure of oxygen we were able to quantify the development of shunt and ventilation/perfusion (V/Q) mismatch over the course of his illness. Shunt and low V/Q gradually improved in the week following admission but deteriorated following general anaesthesia for nailing of the femur.
Timing of removal of the laryngeal mask airway
Authors: Nunez J. , Hughes J. , Wareham K. , Asai T.
Published: March 2003

Previous studies reported that complications associated with removal of the laryngeal mask were more frequent in awake patients than in anaesthetised patients; however, these studies did not comply with the method described in the manufacturer's instruction manual. The reported incidences of regurgitation during the use of the laryngeal mask also differ considerably between studies. We studied these factors in 66 patients in whom the method described in the manual was used. After induction of anaesthesia, the laryngeal mask and a pH probe were inserted and the cuff of the mask was inflated with a minimum volume of air. Anaesthesia was maintained with nitrous oxide and isoflurane in oxygen. At the end of the operation, we randomly allocated patients to one of two groups and the laryngeal mask was removed either while they were still deeply anaesthetised or after they had regained consciousness. No apparent regurgitation occurred in any patient during operation, but one patient in the anaesthetised group regurgitated immediately after removal of the mask. The incidence of complications during or after removal of the laryngeal mask was significantly greater in the anaesthetised group than that in the awake group (p << 0.001; difference [95% CI]: 48.5 [30.5–66.5]%). Therefore, the laryngeal mask can be safely left in place until the patient has regained consciousness after emergence from anaesthesia.
The acute pain service: effective or expensive care?
Authors: Tighe S. Q. M. , Bie J. A. , Nelson R. A. , Skues M. A.
Published: March 2003

The effect of introducing an Acute Pain Service into a District General Hospital was evaluated by conducting an audit of pain, emesis, sleep and satisfaction before and after inception. A total of 1518 questionnaires were collected, in which surgical patients had been asked to assess their experience pre‐ and postoperatively. The introduction of an Acute Pain Service significantly (p < 0.0001) improved in‐patient perception of pain relief upon return of consciousness after anaesthesia and for 2 days postoperatively, when compared with the experience before its inception. The incidence of emetic sequelae did not increase and both patient satisfaction (p < 0.001) and sleep pattern (p < 0.05) in hospital were significantly improved. An estimate of the economic benefit suggests that the development of Acute Pain Services may be cost effective as well as providing an improved quality of service for patients undergoing surgery.
Pouch of Douglas block for laparoscopic sterilisation
Authors: Haldane G. , Stott S. , McMenemin I.
Published: March 2003

The use of local anaesthetic has been shown to reduce the incidence of pain after laparoscopic sterilisation and the need for opioid analgesia from day surgery. We investigated a technique in which a catheter is placed in the pouch of Douglas allowing repeated administration of local anaesthetic in the postoperative period. Forty patients were randomly allocated pre‐operatively into one of two groups to receive in a double‐blind manner either lignocaine 1% or normal saline. Pain was assessed using visual analogue and subjective scoring systems. Postoperative pain scores were significantly reduced (p < 0.05) after injection of lignocaine through the catheter. There were no complications related to the technique and no evidence of local anaesthetic toxicity. Lignocaine instilled into the Pouch of Douglas is an effective method for postoperative pain relief after laparoscopic sterilisation.
Incident reporting in acute pain management
Authors: Chen P. P. , Ma M. , Chan S. , Oh T. E.
Published: March 2003

Incident reporting is an effective tool for continuous quality improvement in clinical practice. A prospective study on voluntary incident reporting in pain management was conducted at a major teaching hospital in Hong Kong. Over a 12‐month period, 53 incidents were reported in 1275 patients who received pain relief treatments which were supervised by the acute pain service. The majority of the incidents were first detected by the pain team. The most common incidents involved delivery circuits, delivery pump and drug administration. A large proportion (81.4%) of the incidents were thought to be preventable. Human factors were involved in 41.9% of the patients reported, most commonly associated with unfamiliar technique/inexperience, inattention and inadequate communication. Four patients developed major morbidity of which two were attributed to inadequate analgesia, while three others had major physiological changes without morbidity. Strategies have been formulated to prevent further occurrence of these incidents. We propose that incident reporting is a potentially useful tool in identifying and preventing adverse events in postoperative pain management.
Suxamethonium, masseter spasm and later malignant hyperthermia
Authors: Ramirez‐R J. A. , Cheetham E. D. , Laurence A. S. , Hopkins P. M.
Published: March 2003

A 25‐year‐old man admitted with severe upper torso trauma displayed masseter muscle spasm after suxamethonium given during resuscitation. Anaesthesia was initially maintained with intravenous agents during transfer and X‐ray angiography. However, during surgery to correct a brachial artery injury, malignant hyperthermia was triggered when isoflurane was given, 2.5 h after the suxamethonium. He responded to treatment, including dantrolene administration. Peak serum and urine myoglobin were 12 947 μg.l−1 and 54 571 μg.l−1, respectively, while maximum serum creatinine kinase was 17 300 IU. The patient made an uneventful recovery and later proved positive for malignant hyperthermia susceptibility on muscle contracture tests.
Gallstones and isoflurane hepatitis
Authors: Meldrum D. J. , Griffiths R. , Kenna J. G.
Published: March 2003

This report is of a case of a previously fit 65‐year‐old woman who developed postoperative liver dysfunction following an anaesthetic involving isoflurane. Biliary ultrasound demonstrated gallstones. However, serum antibodies to trifluoroacetylated proteins were detected, suggesting that immune sensitisation to the anaesthetic could have contributed to the impaired liver function.
Position and shape of the diaphragm: implications for atelectasis formation
Authors: Reber A. , Nylund U. , Hedenstierna G.
Published: March 2003

To evaluate diaphragm movement, 18 consecutive patients undergoing surgery under general anaesthesia were allocated to Group 1 (n = 9: no neuromuscular paralysis) or Group 2 (n = 9: neuromuscular paralysis achieved with pancuronium). Spiral computerised tomography was performed awake and during anaesthesia at end‐expiratory level and, additionally, in four patients (Group 2) at end‐inspiration for subsequent analysis. There was a significant cephalad displacement of the most cephalad point of the diaphragm dome at functional residual capacity, particularly in its dependent portion, in the pancuronium group. During anaesthesia with no persisting muscle paralysis, there was only a minor and insignificant cephalad shift of the diaphragm dome. However, regional analysis showed that the most dorsal part of the diaphragm was significantly displaced cephalad. Compared with conscious, spontaneous breathing, mechanical ventilation decreased the inspiratory displacement of the dependent part of the muscle. This minor movement of the diaphragm may play an additional role in atelectasis formation.
Needle phobia and malignant vasovagal syndrome
Authors: Hart P. S. , Yanny W.
Published: March 2003

A case is reported in which suspicion of malignant vasovagal syndrome was aroused by a history of faints and needle phobia. The vasovagal response was successfully avoided using a gaseous induction of anaesthesia with sevoflurane. Intravenous access was achieved under general anaesthesia. The diagnosis of malignant vasovagal syndrome was confirmed postoperatively using a head‐up tilt table test. An outline of the pathophysiology of the syndrome gives some indication for suitable anaesthetic management strategies in similar cases.
Pressure changes over the anterior neck during tracheal and oesophageal intubation
Authors: Cameron A. E. , Hyde R. A. , Sivalingam P. , Asbury A. J.
Published: March 2003

Pressure changes were measured on the skin over the cricoid and thyroid cartilages during intubation of the oesophagus or trachea in 21 consenting patients. A 100‐ml bag of saline was firmly fixed to the anterior neck and the pressure changes in the bag recorded. Typical and distinctively different pressure patterns for tracheal and oesophageal intubation were recorded. Oesophageal intubation was accompanied by a statistically significantly higher and longer pressure rise and, most characteristically, by an obvious and sustained rise in baseline pressure. This method is, however, neither practical nor recommended for clinical use in detecting accidental oesophageal intubation. Capnography should always be used during tracheal intubation as an ongoing capnographic waveform provides the only guarantee of correct tracheal placement.
Neuromuscular blocking effects and train‐of‐four fade with cisatracurium: comparison with other nondepolarising relaxants
Authors: Carroll M. T. , Mirakhur R. K. , Lowry D. W. , McCourt K. C. , Kerr C.
Published: March 2003

Neuromuscular blocking drugs exhibit different degrees of fade in response to train‐of‐four stimulation believed to represent their relative prejunctional effects. The present study was designed to compare the train‐of‐four fade after cisatracurium and compare this with other commonly used muscle relaxants. Train‐of‐four fade during onset and recovery of block were recorded after administration of cisatracurium 0.05 or 0.1 mg.kg−1, atracurium 0.5 mg.kg−1, vecuronium 0.08 mg.kg−1, mivacurium 0.15 mg.kg−1 or rocuronium 0.6 mg.kg−1 to patients anaesthetised with fentanyl, nitrous oxide and a propofol infusion. Neuromuscular monitoring was by stimulation of the ulnar nerve and recording the force of contraction of the adductor pollicis muscle. The onset and recovery of block were also measured. Train‐of‐four fade during onset of block was greater with the lower dose of cisatracurium compared with the higher dose of cisatracurium and all other relaxants. Train‐of‐four fade during recovery was similar. The median times (and ranges) for the onset of maximum block were 3.4 (2.1–5.6), 1.5 (1.2–2.3), 2.1 (1.2–2.6), 2.0 (1.5–2.7) and 1.0 (0.7–1.3) min for cisatracurium 0.1 mg.kg−1 and atracurium, mivacurium, vecuronium and rocuronium, respectively. The median times (and ranges) for the recovery of T1 to 25% of control and to a train‐of‐four ratio of 0.8 were 41 (21–50) and 65 (40–78); 43 (37–54) and 69 (58–79); 15 (11–20) and 25 (19–30); 31 (23–46) and 60 (45–117); and 33 (18–57) and 50 (28–76) min following cisatracurium, 0.1 mg.kg−1, atracurium, mivacurium, vecuronium and recuronium, respectively.
The influence of intrathecal fentanyl on the characteristics of subarachnoid block for Caesarean section
Authors: Shende D. , Cooper G. M. , Bowden M. I.
Published: March 2003

Forty healthy parturients scheduled for elective Caesarean section were randomly allocated to receive either 0.3 ml 0.9% saline (control group, n = 20) or 15 μg (0.3 ml) fentanyl (treatment group, n = 20) added to 2.5 ml 0.5% hyperbaric bupivacaine given intrathecally in the sitting position. A sensory block to T4 was achieved after 6.5 min in those who received fentanyl compared to 8.0 min in the control group; this was not significantly different. The highest level of sensory block achieved in both groups was similar. Ephedrine was required earlier (p < 0.05) in those who received fentanyl but the total requirement of ephedrine intra‐operatively was similar. Fentanyl significantly improved the quality of intra‐operative surgical anaesthesia as none of the patients in the treatment group complained of discomfort compared with seven in the control group (p < 0.05). Similarly those in the treatment group had better comfort scores as evaluated by visual analogue score (p < 0.01). Regression of anaesthesia to T12 took longer (184 vs 156 min, p < 0.05) in those who received fentanyl but this did not affect the total requirement of morphine in the first 24 h after operation. There was no difference in the incidence of side effects in the mother and no adverse effects were detected in the baby. The results indicate that adding 15 μg fentanyl to hyperbaric bupivacaine for spinal anaesthesia markedly improves intra‐operative anaesthesia for Caesarean section.
The effect of potato starch derived and corn starch derived hydroxyethyl starch on in vitro blood coagulation
Authors: Jamnicki M. , Zollinger A. , Seifert B. , Popovic D. , Pasch T. , Spahn D. R.
Published: March 2003

We have compared the effects of progressive in vitro haemodilution (30% and 60%) with potato starch derived hydroxyethyl starch and corn starch derived hydroxyethyl starch on blood coagulation in 80 patients using thrombelastography. Both solutions significantly compromised blood coagulation as evidenced by an increase in coagulation time and decreases in angle α, maximum amplitude and coagulation index (p < 0.05). Blood coagulation was more compromised during haemodilution with potato starch derived hydroxyethyl starch as compared with corn starch derived hydroxyethyl starch (p < 0.05). When taking the effect of haemodilution with 0.9% saline into account, haemodilution with both hydroxyethyl starch solutions also augmented clot lysis (p < 0.05), with potato starch derived hydroxyethyl starch having a greater effect than corn starch derived hydroxyethyl starch (p < 0.05). We conclude that potato starch derived hydroxyethyl starch compromises in vitro blood coagulation more than corn starch derived hydroxyethyl starch.
A survey of undergraduate teaching in anaesthesia
Authors: Cheung V. , Critchley L. A. H. , Hazlett C. , Wong E. L. Y. , Oh T. E.
Published: March 2003

Currently, no well accepted and clearly defined ‘core’ curriculum for undergraduate anaesthesia teaching exists. To address this deficiency, we surveyed 73 university departments of anaesthesia and intensive care. Sixty‐five replied from South‐east Asia (12), Australasia (13), the UK and Ireland (28) and Canada (12). A questionnaire containing 37 items ranging from departmental structure to curriculum content was used. We found significant regional differences. Overall, most departments taught pharmacology of anaesthetic drugs (83%), pre‐operative assessment (92%) and care of the unconscious patient (77%). Ninety‐seven per cent taught airway management and intubation and 80% taught intravenous cannulation. Basic life support was taught by 92% and advanced life support by 71%. Fewer than half taught advanced trauma life support principles (44%). Critical care teaching was less well defined, but a consensus of schools taught respiratory failure and ventilation, management of circulatory shock and principles of sepsis and multi‐organ system failure. Practical clinical skills were taught mainly using patients and simulators, 46% had a skills laboratory and six employed a resuscitation officer. However, it should be noted that we did not assess the quality and outcome of teaching.
A bronchogenic cyst in an infant causing tracheal occlusion and cardiac arrest
Authors: Harle C. C. , Dearlove O. , Walker R. W. M. , Wright N.
Published: March 2003

A 3‐month‐old infant treated for 3 weeks for suspected bronchiolitis, developed episodes of profound desaturation. A lateral X‐ray showed displacement and compression of the trachea. Respiratory arrest, from which she was successfully resuscitated, occurred just before MRI scan. The mass was removed at thoracotomy and a histological diagnosis of a bronchgenic cyst was made. Mediastinal masses in babies are relatively rare, and the situation in which they present with acute respiratory distress may prove extremely challenging to the anaesthetist. Bronchogenic cysts are difficult to diagnose pre‐operatively and awareness may assist in the peri‐operative management of these infants.
The use of epidural ropivacaine in high doses for the management of pain from invasive carcinoma of the cervix
Authors: Harrison G. R.
Published: March 2003

A case is presented of a young woman with advanced cervical cancer invading the rectum and sacral nerves giving rise to an intractable pain state. The management of her symptoms using a domicillary infusion of diamorphine with high doses of ropivacaine is described. It is believed that this is the first presentation of ropivacaine being used in daily doses approaching 2 g, and the associated problems are discussed.
Cerebral perfusion monitored using transcranial Doppler during acute anaphylaxis
Authors: Fox A. J. , McLaren I. M. , Naylor A. R.
Published: March 2003

We present a case of severe acute anaphylaxis that occurred during preparation of a patient for carotid endarterectomy. Intra‐arterial blood pressure and transcranial Doppler monitoring had been established before the anaphylactic reaction began and therefore the changes in arterial blood pressure and middle cerebral artery blood‐flow velocity could be observed as they happened. This made it possible to assess directly the effectiveness of our management, which followed the resuscitation guidelines issued by the Association of Anaesthetists. In particular, this was a rare opportunity to confirm whether the recommended management is effective in restoring cerebral blood flow, and not just blood pressure, in a ‘real life’ situation, as most resuscitation information is based on laboratory‐based animal studies. Evidence is presented which suggests that the administration of adrenaline in this setting is associated with increases in cerebral blood flow that are independent of arterial blood pressure.
The use of cricoid pressure with the intubating laryngeal mask
Authors: Harry R. M. , Nolan J. P.
Published: March 2003

Unexpected difficulty with tracheal intubation contributes to anaesthetic morbidity and mortality. The intubating laryngeal mask is effective in facilitating blind intubation. We have evaluated the effect of cricoid pressure on the ability to insert an intubating laryngeal mask, and to pass a tracheal tube through it. Insertion and intubation through the mask were attempted in 50 patients, Mallampati grade 1–3, randomly allocated to cricoid and noncricoid pressure groups. Tracheal intubation was successful in 21 (84%) of the noncricoid group and 13 (52%) of the cricoid group (p = 0.03). Cricoid pressure may have to be released to allow correct placement and intubation through the intubating laryngeal mask.
Hemispheric‐synchronisation during anaesthesia: a double‐blind randomised trial using audiotapes for intra‐operative nociception control
Authors: Kliempt P. , Ruta D. , Ogston S. , Landeck A. , Martay K.
Published: March 2003

The possible antinociceptive effect of hemispheric‐synchronised sounds, classical music and blank tape were investigated in patients undergoing surgery under general anaesthesia. The study was performed on 76 patients, ASA 1 or 2, aged 18–75 years using a double‐blind randomised design. Each of the three tapes was allocated to the patients according to a computer‐generated random number table. General anaesthesia was standardised and consisted of propofol, nitrous oxide 66%/oxygen 33%, isoflurane and fentanyl. Patients breathed spontaneously through a laryngeal mask and the end‐tidal isoflurane concentration was maintained near to its minimum alveolar concentration value of 1.2%. Fentanyl was given intravenously sufficient to keep the intra‐operative heart rate and arterial blood pressure within 20% of pre‐operative baseline values and the fentanyl requirements were used as a measure of nociception control. Patients to whom hemispheric‐synchronised sounds were played under general anaesthesia required significantly less fentanyl compared with patients listening to classical music or blank tape (mean values: 28 μg, 124 μg and 126 μg, respectively) (p < 0.001). This difference remained significant when regression analysis was used to control for the effects of age and sex.
Definitions in obstetric anaesthesia: how should we measure anaesthetic workload and what is ‘epidural rate’?
Authors: Yentis S. M. , Robinson P. N.
Published: March 2003

Crude delivery rate is used to calculate requirements for consultant anaesthetic sessions in the UK, but this calculation is arbitrary and ignores differences in case‐mix between units. The term ‘epidural rate’ is commonly used to indicate regional anaesthetic activity but has never been defined. We challenge both these concepts and illustrate our argument by applying different definitions of obstetric anaesthetic activity to prospectively collected maternity data from 31 211 deliveries over 5 years in two hospitals. Number of anaesthetic interventions is a more accurate reflection of obstetric anaesthetic activity than number of deliveries, with Northwick Park Hospital having about 200–600 more deliveries per year than Chelsea & Westminster Hospital but about 300–400 fewer anaesthetic interventions per year. ‘Epidural rate’ varied by up to 30% according to the definition used. We conclude that number of anaesthetic interventions should replace crude number of deliveries as a measure of obstetric anaesthetic activity, and that the term ‘regional anaesthesia rate’ should replace ‘epidural rate’.
Structured sedation programme for magnetic resonance imaging examination in children
Authors: Keengwe I. N. , Hegde S. , Dearlove O. , Wilson B. , Yates R. W. , Sharples A.
Published: March 2003

One thousand, eight hundred and fifty‐seven patients underwent magnetic resonance imaging following the establishment of a structured sedation programme. Forty‐eight of these patients came from the intensive care unit with a secure airway and were therefore excluded from any further analysis. Oral sedation was to be given to children aged 5 years and below. For children ≥ 6 years old, oral sedation could be given only if their level of co‐operation was judged to be inadequate by the referring physician. Oral sedation consisted of chloral hydrate 90 mgkg−1 (maximum 2.0 g) orally with or without rectal paraldehyde 0.3 ml.kg−1. All magnetic resonance imaging requests for children who failed oral sedation as well as those referred for general anaesthesia from the outset were reviewed by a consultant anaesthetist who then allocated patients to undergo the procedure with either general anaesthesia or intravenous sedation. Scans requiring intravenous sedation or general anaesthesia were performed in the presence of a consultant anaesthetist. Intravenous sedation consisted of either a propofol 0.5 mgkg−1 bolus followed by an infusion (maximum 3 mgkg−1.h−1) or midazolam 0.2–0.5 mgkg−1 boluses. General anaesthesia was given using spontaneous ventilation with a mixture of 66% nitrous oxide in oxygen and isoflurane following either inhalation (sevoflurane) or intravenous (propofol) induction. One thousand and thirty‐nine (57.4%) of the scans were done without sedation whereas 93 scans were performed during the consultant anaesthetist supervised sessions. Oral sedation failed in 50 out of 727 patients (6.9%). Eighty‐seven per cent of children aged 5 years and below needed sedation compared with 4.5% of those aged over 10 years. Two patients who had only received chloral hydrate developed significant respiratory depression. This structured sedation programme has provided a safe, effective and efficient use of limited resources.
Syringe labels in anaesthetic induction rooms
Authors: Radhakrishna S.
Published: March 2003

A survey of 35 hospitals in the United Kingdom has uncovered a wide variety of syringe drug labels. Use of different systems in different hospitals may result in wrong drug administrations, particularly when trainees move from one hospital to another. There is an urgent need to standardise the colour coding of syringe labels in the United Kingdom. Such standards are already in place in Australia, New Zealand and in the United States of America. This survey of syringe drug labels highlights the existing risks and recommendations for change are made.
Intensive care: preparations for the Millennium A survey of hospitals in the north of England
Authors: Baker S. S. , McInnes A. , Clarke F. L. , Lawler P. G.
Published: March 2003

In order to assess preparedness for the Millennium, we carried out a telephone survey of all Intensive Care Units in the former Northern Region. The survey disclosed wide variation in the current and planned provision of back‐up power and central services, proposed staffing levels and expected demand.
Haemodynamic changes during thoracoscopic surgery The effects of one‐lung ventilation compared with carbon dioxide insufflation
Authors: Brock H. , Rieger R. , Gabriel C. , Pölz W. , Moosbauer W. , Necek S.
Published: March 2003

We investigated the haemodynamic and respiratory effects of one‐lung ventilation and carbon dioxide insufflation in 13 adult patients undergoing video‐assisted thoracoscopy. Cardiorespiratory variables were determined during carbon dioxide insufflation at intrahemithoracic pressures of 5, 10 and 15 mmHg, and after 5 and 15 min of one‐lung ventilation. Carbon dioxide insufflation was associated with a clear deterioration in circulatory function. The cardiac index decreased subsequent to increasing intrathoracic pressures. The mean cardiac index (SD) at pressures of 10 and 15 mmHg was 1.86 (0.39) and 1.52 (0.46), respectively, and may be compared with the reduced venous return consistent with tension pneumothorax. One‐lung ventilation did not affect haemodynamic variables but reduced arterial oxygenation indices (Pao2/FIo2) from 424.29 (160.79) after induction of anaesthesia, to 207.72 (125.50) after 5 min and 172.04 (72.03) after 15 min of one‐lung ventilation, respectively. The oxygenation index was not influenced by intrahemithoracic carbon dioxide insufflation. One‐lung ventilation via a double‐lumen endobronchial tube is safe and convenient for video‐assisted thoracoscopic surgery. It has no further consequences on haemodynamic variables, whereas the compression of the lung by carbon dioxide insufflation may cause circulatory dysfunction.
Intra‐ocular pressure and haemodynamic changes after tracheal intubation and extubation: a comparative study in glaucomatous and nonglaucomatous children
Authors: Madan R. , Tamilselvan P. , Sadhasivam S. , Shende D. , Gupta V. , Kaul H. L.
Published: March 2003

This prospective, controlled study was conducted to compare the effects of tracheal intubation and extubation on intra‐ocular pressure changes and haemodynamic parameters in paediatric patients with and without glaucoma. The children were scheduled for intra‐ocular surgery. Twenty children with normal intra‐ocular pressure and 15 with glaucoma were studied. A standardised general anaesthetic was administered to both groups. After 5 min of anaesthesia, intra‐ocular pressure, heart rate and noninvasive blood pressure were measured. These measurements were repeated 30 s and 2 min after tracheal intubation. Further measurements were taken before, and 30 s and 2 min after extubation. The increase in intra‐ocular pressure after intubation was greater in the glaucomatous group than in the normal group. The increase in intra‐ocular pressure was greater after extubation than intubation in both groups, but was similar in the two groups. However, because of the already increased intra‐ocular pressure in glaucomatous children, they may be at an increased risk of visual damage after intubation and extubation.
Randomised double‐blind comparison of fentanyl, mivacurium or placebo to facilitate laryngeal mask airway insertion
Authors: Cheam E. W. S. , Chui P. T.
Published: March 2003

In a double‐blind randomised study, we compared conditions during insertion of the laryngeal mask airway in 150 patients who received either fentanyl 1 μg.kg−1, mivacurium 0.04 mg.kg−1 or normal saline, before induction of anaesthesia with propofol 2 mg.kg−1. Insertion conditions, including mouth opening, swallowing, gagging or coughing, head or limb movement and ease of insertion, were each graded using a three‐point scale. The median (interquartile range) summed insertion scores were more favourable with the use of fentanyl [8.0 (7.0–9.0)] and mivacurium [7.5 (6.8–8.3)] than with normal saline [9.0 (7.8–10.3); p < 0.01]. Fentanyl and mivacurium decreased swallowing and head or limb movement, and mivacurium improved mouth opening. Insertion conditions were similar between fentanyl and mivacurium, while both prolonged apnoea. Fentanyl and mivacurium are equally effective in facilitating insertion of the laryngeal mask airway following anaesthetic induction with propofol.
Cyclo‐oxygenase isoenzymes: physiological and pharmacological role
Authors: Kam P. C. A. , See A. U‐L.
Published: March 2003

Prostaglandins play important roles in inflammation and the maintenance of normal physiological function of several organ systems. Prostaglandin production requires the conversion of arachidonic acid to the intermediate prostaglandin H2 catalysed by the cyclo‐oxygenase (COX) enzyme. There are two isoforms of the COX enzyme, COX‐1 and COX‐2. These isoforms vary in their distribution and expression but are similar in size, substrate specificity and kinetics. Normal physiological functions are mediated by ‘constitutive’ COX‐1, while the inflammatory response is mediated by ‘inducible’ COX‐2. Current nonsteroidal anti‐inflammatory drugs inhibit both enzymes to varying degrees and can cause adverse effects in the gastrointestinal tract, kidney, respiratory system and platelets. Newer, selective COX‐2 inhibitors offer real hope for safer anti‐inflammatory drugs although their long‐term safety and efficacy need to be studied as questions remain unanswered about possible physiological functions of COX‐2.
Target‐controlled infusion of propofol and remifentanil combined with bispectral index monitoring for awake craniotomy
Authors: Hans P. , Bonhomme V. , Born J. D. , Maertens de Noordhoudt A. , Brichant J. F. , Dewandre P. Y.
Published: March 2003

We describe the target‐controlled administration of propofol and remifentanil, combined with monitoring of the bispectral index, during an awake craniotomy for removal of a left temporo‐parietal tumour near the motor speech centre. Target concentrations of the two drugs were adjusted according to the patient's responses to painful stimuli and surgical events, and the need for speech testing. Allowing the effect‐site concentrations of propofol and remifentanil to decrease during surgery allowed the performance of cortical speech mapping and the testing of the patient's ability to speak. Although the bispectral index was not used as a guide for the administration of the drugs, its value correlated better with the patient's responsiveness than did the predicted effect‐site concentrations of propofol. Side‐effects, comprising hypotension, respiratory depression and airway obstruction, were related to rapid increases in drug infusion rates and were easily managed.
Influence of an anaesthetist on nurse‐led, computer‐based, pre‐operative assessment
Authors: Barnes P. K. , Emerson P. A. , Hajnal S. , Radford W. J. P. , Congleton J.
Published: March 2003

Trained nurses using a rule‐based computer program can successfully carry out pre‐anaesthesia screening. All medical problems and abnormal laboratory results need to be reviewed by an experienced anaesthetist. Following the introduction of this system, there was a reduction in the frequency of cancellations of patients from elective orthopaedic operating lists from 4.8% to 1.8%, a difference that was statistically significant (p = 0.03, CI = [0.6%, 5.5%]). To minimise cancellations from booked operating lists, a booked admissions policy is essential, so that the anaesthetist who will eventually be responsible for patients with medical problems can be identified. Cancellations cannot be avoided completely because some abnormal conditions arise or deteriorate after completion of the screening process. The anaesthetist responsible for the patient's anaesthetic may have different views of the risks involved from those of the anaesthetist undertaking the screening process.
Increases in serum concentrations of cardiac proteins and the prediction of early postoperative cardiovascular complications in noncardiac surgery patients
Authors: Neill F. , Sear J. W. , French G. , Lam H. , Kemp M. , Hooper R. J. L. , Foex P.
Published: March 2003

We investigated the use of measurements of serum concentrations of the cardiac proteins troponins I and T as biochemical markers of myocardial cell damage in 80 patients undergoing vascular or major orthopaedic surgery. Holter electrocardiographic monitoring was carried out before surgery and for 3 days after surgery. Blood samples for troponins I and T and creatine kinase‐MB isoenzyme were taken on each of these 4 days. Outcome was assessed at 3 months using a patient questionnaire, general practitioner follow‐up and case notes review. Silent postoperative myocardial ischaemia was detected in 21 patients; increases in troponins I and T and creatine kinase‐MB occurred in four, six and 17 of these patients, respectively. Eight patients suffered major postoperative complications (cardiac death, myocardial ischaemia, congestive cardiac failure, unstable angina and cerebrovascular accident) and 21 minor complications (poorly controlled hypertension needing increased or new additional treatment, palpitations, increased tiredness or shortness of breath in the absence of known respiratory disease). There were no associations between postoperative ischaemia and cardiac protein concentrations. The relative odds for the associations of major adverse outcome at 3 months after surgery and postoperative ischaemia or increased serum concentrations of the three proteins were 5.39 [95% confidence intervals 1.16–27.67] for postoperative ischaemia; 5.64 [1.07–31.00] for creatine kinase‐MB isoenzyme; 17.00 [2.20–116.54] for troponin T and 13.20 [1.12–135.00] for troponin I. We found troponin T to be the only prospective marker for both major and minor cardiovascular complications (relative odds 10.65 [1.26–252.88]).
The effect of intravenous epinephrine on the bispectral index and sedation
Authors: Andrzejowski J. , Sleigh J. W. , Johnson I. A. T. , Sikiotis L.
Published: March 2003

Eight patients were given a propofol infusion until they no longer responded to loud verbal stimuli, a sedation score of two (modified Observer Assessment of Alertness and Sedation Scale). After receiving 15 µg of intravenous epinephrine, changes in sedation score and bispectral index (BIS) were observed. Mean pulse rate increased from 68 to 96 (SD 10) beat.min−1, mean blood pressure increased from 107/60 (SD 10/8) mmHg to 140/70 (SD 27/14) mmHg, and mean BIS level rose from 63 to 76 (p < 0.005). Sedation scores increased in six of the eight patients. Exogenous catecholamines seem to have an arousal effect on lightly anaesthetised patients. This could be due to changes in neurotransmitter levels in the brain, or due to the effects consequent on increased cardiac output.
Evaluation of predicted and actual length of stay in 22 Scottish intensive care units using the APACHE III system
Authors: Woods A. W. , MacKirdy F. N. , Livingston B. M. , Norrie J. , Howie J. C.
Published: March 2003

The most recent edition of the Acute Physiology and Chronic Health Evaluation provides a prediction of intensive care unit length of stay in addition to the probability of hospital mortality. Intensive care length of stay is an important determinant of intensive care costs and may be an important indicator of quality of care. Data were collected from 22 Scottish intensive care units over a 2‐year period to allow comparison of actual intensive care unit length of stay with that predicted by the Acute Physiology and Chronic Health Evaluation III system. Correlation between actual and predicted stay for individual patients was poor. However, performance of the model for patients, grouped either by predicted length of stay or by intensive care unit, indicated that the model stratified patient groups appropriately while demonstrating a consistent bias. Length of stay in Scottish intensive care units was found to be consistently lower than that predicted by a model which is based on intensive care practice in the USA. Variations in severity of illness in intensive care unit populations cannot readily explain differences in intensive care unit length of stay. The availability of a model capable of predicting length of intensive care stay, based on data reflecting practice in the UK, would compliment current methods of assessing effectiveness of intensive care.
The incidence of transient neurological symptoms after spinal anaesthesia with lidocaine compared to prilocaine
Authors: De Weert K. , Traksel M. , Gielen M. , Slappendel R. , Weber E. , Dirksen R.
Published: March 2003

The purpose of this double‐blind study was to investigate the incidence of transient neurological symptoms after the use of isobaric lidocaine and isobaric prilocaine for spinal anaesthesia. Seventy patients (ASA 1–2, age between 18 and 70 years) were randomly assigned to two groups of 35 patients each, to receive either isobaric 2% lidocaine 4 ml or isobaric 2% prilocaine 4 ml intrathecally, at the L3−4 interspace. One patient in the prilocaine group could not be included because data were incomplete. On the first postoperative day, patients were evaluated for transient neurological symptoms. Pain was scored on a 10‐point scale. Seven patients (20%) in the lidocaine group had transient neurological symptoms with a mean pain score of 5.3, whereas no patient in the prilocaine group had these complaints (p = 0.006). Symptoms disappeared within 4 days. Prilocaine results in a lower incidence of transient neurological symptoms than lidocaine intrathecally and therefore it is more suitable for short surgical procedures.