This study was designed to investigate whether the advantages of low- and minimal-flow anaesthesia can be combined with the laryngeal mask airway (LMA). Seventy female patients undergoing routine gynaecological surgery were investigated. After induction of anaesthesia and after positioning a laryngeal mask airway nos 3 and 4, patients were ventilated for 20 min with a fresh gas flow of 6L min−1. Thereafter, the flow was reduced to 1L min−1 in 50 patients and to 0.5L min−1 in 20 patients. Once in the proper position,the LMA allowed flow reduction in all patients, indicating that no gas leakage occurred. It is concluded,that the application of low-flow and even minimal-flow anaesthesia is an alternative to high-flow anaesthesia. It can result in high annual savings and minimization of pollution. However, its use should be restricted to those anaesthesiologists who are experienced with the laryngeal mask airway and minimal-flow anaesthesia.

Forty-eight patients scheduled for elective cardiac surgery were randomly assigned to receive aprotinin in the following doses: 0.2 mg kg−1 (group A), 0.7 mg kg−1 (group B), 1 mg kg−1 (group C) and 1.4 mg kg−1 (group D). Clot formation was analysed by thromboelastography immediately after induction of anaesthesia and again 30 min after administration of aprotinin. Rate of clot formation was assessed using R (reaction time = rate of initial fibrin formation), K (clot formation time = rate of fibrin build-up and cross linking) and angle of clot formation (denoting speed at which solid clot forms). Strength of the clot was assessed by maximal amplitude of clot formation (MA)and % lysis after 30 and 60 min. Significant reduction of R and K times and increase in angle of clot formation was observed in groups A and B. This effect was not apparent in the other groups. In group D, an increase in R time was noted. These findings indicate a dose dependent effect of aprotinin on rate of clot formation with an earlier clot formation at low doses.

The interaction of aprotinin with normal coagulation was studied in blood samples obtained from 10 healthy subjects. Each sample was simultaneously tested in four different preparations : NaCl-treated blood: 0.03 mL 0.9% NaCl in 0.33 mL blood; aprotinin treated blood : 0.33 mL blood+aprotinin in 0.03 mL in aliquots to obtain a final blood concentration of respectively 50 KIU mL−1; 100 KIU mL−1 and 200 KIU mL−1. The coagulation process was analysed by thromboelastography. R-time, reflecting intrinsic coagulation, increased in a dose dependent manner between NaCl-treated and aprotinin-treated blood. These findings suggest a dose dependent impairment of intrinsic coagulation by aprotinin.

We have examined the effect of propofol on the neutrophil respiratory burst. Chemiluminescence was used as a measure of the respiratory burst following stimulation with 10−5m N-formyl-L-methionyl-L-leucyl-L-phenylalanine.Propofol 1.25, 2.5 and 5.0 × 10−5m inhibited neutrophil chemiluminescence by 29.6, 43.0 and 57.6%, respectively, in neutrophils prepared from healthy adult volunteers, and by 25.5, 37.4 and 54.7% in cells from patients with severe sepsis. We conclude that propofol interferes with the ability of human neutrophils to generate reactive oxygen species.

Eleven adult patients with severe head injuries caused by blunt trauma, (Glasgow Coma Score of eight or less after resuscitation), were studied while being mechanically ventilated and sedated in the intensive care unit (ICU). In a double blind randomized cross over trial each patient received a bolus of suxamethonium (1 mg kg−1) or an equal volume of saline(0.02 mL kg−1) before planned physiotherapy. Intracranial pressure (ICP) and mean arterial pressure(MAP) were measured continuously for 10 min after each injection. There were no significant changes in intracranial pressure or cerebral perfusion pressure(CPP) following the administration of suxamethonium or saline. Suxamethonium appears to be a safe drug to use on sedated persons with severe head injuries following blunt trauma.

Pipecuronium bromide, a long acting non-depolarizing neuromuscular blocking agent was administered to four groups of 10 patients using the priming technique.The effects of the combination of two different priming doses (0.01 or 0.015 mg kg−1) given at two different time intervals (3 or 4 min) before the ‘main’ intubating dose (0.07 or 0.065 mg kg−1) were investigated. Onset times were recorded and the intubation conditions were scored and compared with a group of patients receiving the same total amount of pipecuronium(0.08 mg kg−1) in a single bolus injection. Intubating conditions at 90 s after administration of the intubating dose were found to be significantly improved in all primed groups but the onset times, evaluated using the response of the adductor pollicis muscle to a single twitch stimulation, were similar to that observed after the single bolus injection. The optimal priming combination is considered to be 0.01 mg kg−1 of pipecuronium followed 3 to 4 min later by 0.07 mg kg−1.

A 21-year-old female weighing 55 kg was anaesthetized for facial reconstruction. After an initial bolus of pancuronium 5 mg and top-up doses of 2 mg at 135 min and 1 mg at 290 min and 335 min, no further relaxant was given for 130 min at which time neuromuscular transmission appeared fully recovered with a full train-of-four twitches and a sustained response to 50 Hz stimulation of the posterior tibial nerve. Subsequently, a single dose of mivacurium 8 mg(2 X ED95) produced extended paralysis with no response to train-of-four stimulation for 85 min. The prolonged effect of mivacurium may have been because of inhibition of plasma cholinesterase by pancuronium. The serum cholinesterase activity 12 h after surgery was 0.38 units mL−1 (normal range 0.65–1.0 units mL−1). There was no evidence of atypical choylinesterase.

The efficacy of ondansetron 4 mg was compared with metoclopramide 10 mg for the prevention of post-operative nausea and vomiting in patients after major gynaecological abdominal surgery. Anaesthesia was standardized using thiopentone, atracurium and methadone for induction followed by isoflurane in nitrous oxide-oxygen mixture. Fifty patients were randomized in a double-blind fashion to either receive intravenous(i.v.) ondansetron 4 mg or metoclopramide 10 mg during closure of the pelvic peritoneum. The incidence and frequency of vomiting, and the incidence of severe nausea was recorded for 24 h after surgery. One patient was excluded because of respiratory depression. In the first 4 h after surgery, five patients (20%) in the ondansetron group (n = 25) and eight patients (33%) in the metoclopramide group (n = 24) vomited, whereas at 4–12 h, this increased to 11 patients (44%) and nine patients (37.5%) respectively. The incidence was 52 and 37.5% respectively in the subsequent 12–24 h. The highest incidence of nausea was in the first 4 h after surgery, being 56 and 37.5% in the ondansetron and the metoclopramide groups respectively. This decreased to less than 25% in both groups in the 12–24 h period. Ondansetron 4 mg and metoclopramide 10 mg had similar but short lasting efficacy for the prevention of vomiting in patients who received continued opioid analgesia after major gynaecological surgery.

In a randomized, double-blind, double-dummy, single-dose, parallel-group study, oral ibuprofen arginine(400 mg) was compared with intramuscular (i.m.)morphine sulphate (5 or 10 mg) for post-operative pain relief after orthopaedic surgery in 120 patients. The study medication was administered post-operatively at the time when each patient first requested pain relief for moderate to severe pain. Assessment of pain intensity and pain relief was made using standard visual analogue scales and verbal rating scores. In all three groups, there was a reduction in pain compared with baseline, measured by visual analogue scales and verbal rating scores, at all time points up to completion of the study at 240 min. For example, visual analogue scales decreased by 35 (10–52)mm at 1 h in the morphine 5 mg group, 24 (12–39)mm in morphine 10 mg group and 21 (8–38)mm in the ibuprofen arginine group (median and inter-quartile range). Verbal rating scores showed a similar pattern. Comparing the groups over the whole study period using the sum of pain intensity differences showed no significant differences in pain experience between the groups.Assessment of total pain relief also showed no significant differences. The incidence and types of side effect seen were similar in the three groups.

The case of a 64-year-old man who was admitted to hospital with fever, general deterioration and anorexia is reported. For the past 4 years, the patient had been receiving corticosteroid therapy for a chronic inflammatory demyelinating polyradiculoneuropathy. Soon after admission the patient developed respiratory insufficiency as a result of a massive pneumonitis, with severe hypoxia, acute anaemia, acute renal failure and a systemic inflammatory response syndrome (SIRS) requiring admission to the Intensive Care Unit (ICU). All faecal, bronchial, duodenal and urine samples showed Strongyloides stercoralis larvae. Despite antihelmintic therapy and cardiorespiratory support, the patient died from the consequences of irreversible shock. Strongyloidiasis is present worldwide and can be a chronic, essentially asymptomatic infection. This nematode can produce an overwhelming hyperinfection syndrome, especially in patients showing deficient cell-mediated immunity. Strongyloides hyperinfection syndrome is frequently fatal but is potentially a treatable clinical condition. Patients undergoing immunosuppressive therapy or with suspected immunity deficiency (HIV infection, malnutrition, lymphomas, leukaemias or other neoplasia treated with systemic radiotherapy or chemotherapy) must be also monitored for opportunistic Strongyloides stercoralis infection, because clinical manifestation of the systemic hyperinfection syndrome can be rather non-specific.

The thermoregulatory responses in 13 haemodynamically stable patients were evaluated over a 7-h period following coronary artery bypass graft surgery. Cutaneous vasoconstriction was defined by a forearm-to-fingertip skin temperature gradient (ΔTskin) ≥ 4°C and muscular hyperactivity was assessed by integrating the electromyographic signals (iEMG). Blood gases and lactate were measured in arterial, mixed venous and femoral venous blood. After arrival in ICU, we observed: (1) mild central hypothermia (Tc = 34.8±0.6°C) and elevated peripheral vascular resistance in all the patients; (2) ΔTskin ≥ 4°C in 11 of 13 patients that persisted until a median Tc of 37.1°C was achieved; (3) a transient increase in iEMG (±18%)was accompanied by an increase in total body O2 uptake (+28%); (4) elevated muscle O2 extraction rate(56±18% after 3 h) and lactate release. These data suggest that residual hypothermia in sedated patients safter cardiac surgery elicits appropriate thermoregulatory responses that are associated with transient O2 supply/uptake mismatch within skeletal muscles.

This study was designed to determine the intra-operative incidence of right-sided ventricular ischaemia and any association with left ventricular ischaemia. In 60 patients, undergoing coronary artery bypass grafting surgery, a right-sided precordial lead V5R was used. ST segment deviation of more than 1 mm in V5R was considered significant for myocardial ischaemia. Right ventricular ischaemia occurred in 14 patients(23.3%) but was not associated with left ventricular inferior wall ischaemia. In 4 patients (6.6%) presenting with right ventricular ischaemia, ischaemia of the left inferior wall also developed but in all cases was transient and disappeared by the end of surgery. No myocardial infarction was detected in the post-operative period. The present study showed that the use of a right-sided lead may improve intra-operative electrocardiographic monitoring, by revealing ischaemia in those patients in whom ECG abnormalities were not detected by conventional leads. The transient right ventricular ischaemia recorded in this study was probably related to a reduced hypothermic protection of the right ventricle during aortic cross clamping.

This study was designed to determine whether the introduction of epidural infusions containing fentanyl and bupivacaine has affected the mode of delivery in primiparous women attending our maternity department. We reviewed retrospectively the computerized records of 4362 consecutive primiparous women in labour. All the women were admitted with the expectation of a vaginal delivery. The results were analysed using logistic regression analysis adjusted for age, weight, gestation, cervical dilatation at epidural insertion, use of oxytocin, the year of entry into the study and the type of epidural block received. In women receiving an epidural block at 3–6 cm cervical dilatation (n = 1534), those who received an infusion were significantly less likely to have an emergency Caesarean section than those having intermittent ‘top-ups’ (P = 0.0019). In the same subgroup of women, the Caesarean section rate specifically for failure to progress followed the same trend, but just failed toreach statistical significance (P = 0.058). This provides evidence to support the theory that epidural infusions containing a low dose bupivacaine/fentanyl combination may reduce the risk of Caesarean section in primiparous women.

Pulmonary hypertension is usually treated with intravenous (i.v.) vasodilators, but their use is limited by systemic effects. In the current study, we compared the effects of inhaled nitric oxide and intravenous nitroglycerine on pulmonary and systemic haemodynamic responses as well as on gas exchange measurements in anaesthetized pigs whose pulmonary pressure was increased by hypoxia (FiO2 = 15%). Both treatments reduced pulmonary pressure to the control level. Inhaled nitric oxide did not affect systemic arterial pressure but intravenous nitroglycerine decreased it from 126.2 to 108.8 mmHg (P = 0.04). Unlike intravenous nitroglycerine, inhaled nitric oxide increased arterial PaO2 from 5.3 to 5.9 kPa (P = 0.02). Both treatments diminished central venous pressure and left atrial pressure, suggesting a possible cardiac effect. Inhaled nitric oxide was shown to be a potent pulmonary vasodilator which attenuated pulmonary hypertension and improved arterial oxygenation without important direct effects on systemic pressure in porcine hypoxia-induced pulmonary hypertension.

A patient is presented who obtained only an L1 sensory block, which was inadequate for her procedure, from continuous spinal anaesthesia despite appropriate doses of 0.5% plain bupivacaine. She then developed a high spinal block after an epidural was sited and a test dose given in the sitting position. The possible mechanisms for this are discussed.