A postal survey was carried out on every 71st person aged between 18 and 80 in the population registers in County Regierungsbezirk Karlsruhe in the State of Baden-Würtemberg. It asked 2127 persons whether they had, in the previous 6 months, experienced any form of unduly prolonged pain (as distinct from brief intercurrent self-limiting episodes related to injury inflammation etc.) and, if so, to specify its location, duration, severity and persistence. It also sought information on the resulting calls on healthcare professionals and the degree of satisfaction with treat-ments received. The age and gender distributions of the sample selected for survey matched those in the population from which it was drawn. Of the 1420 respondents, only 1304 declared their age and gender – a condition for inclusion in the analysis. Of these, 610 reported some form of unduly prolonged pain, which had lasted more than a year in 530. For all pain lasting longer than a year, the estimated prevalence of mild pain was 11%, severe 25% and intolerable 3.5%: the corresponding estimates for persistent as opposed to episodic pain were 2% for mild, 10% for severe and 1% for intolerable. Pain was present in more than one anatomical location in most of those who reported it. Musculoskeletal pain was overwhelmingly the most common.Increasing age, obesityandbeing femalepre-disposed to the reporting of pain, with women being more liable to report headache and pain in the neck and shoulder.One hundred and thirty-six pain reporters either gave no information on consultation or sought no help from healthcare professionals: a third of the remainder consulted more than one professional, with general practitioners and specialists in physical medicine (niedergelassener Orthopäde) being the most common. A wide variety of treatments were used, with oral medications, massage, exercises, mud pack and heat treatment being the most popular; two-thirds of sufferers used more than one type of treatment. The most popular types of treatment tended also to be the most successful, except for oral medication (which was also the most heterogeneous). Multiple logistic regression analyses identified consistent associations between duration and severity of pain, the number of sites where it was reported, the numbers of healthcare professionals consulted and the number of treatments tried, and the same groupings of features were associated with decreased likelihood of overall satisfaction with treatment received.

The physical compatibility of thiopentone and propofol mixtures was investigated. The investigations used were macroscopic and microscopic observations, zeta potential and oil droplet size measurements. There was no evidence of instability in the mixtures. The thiopentone–propofol mixture has the potential advantage of reducing the pain on injection, provides synergistic interaction, does not prolong recovery when used for induction of anaesthesia, may reduce the incidence of convulsions and is cost-effective.

The purpose of this study was to identify whether the central extracellular fluid volume status following and pypo- hypervolaemia can be measured by the initial distribution volume of glucose or by the extravascular lung water. These two estimates were compared with the initial distribution volume of sucrose which has been used as an indicator for the measurement of the extracellular fluid volume. The above three estimates were determined by the administration of glucose, chilled saline and sucrose solutions, before and after haemorrhage (30 mL kg−1), and subsequent fluid load (lactated Ringer's solution 90 mL kg−1). The distribution volumes of glucose and sucrose decreased after haemorrhage and increased after fluid load compared with normovolaemic values, and a linear correlation was obtained between these two distribution volumes (r=0.93, P<0.001, n=36). How ever, the extravascular lung water remained statistically unchanged throughout the procedure, despite a weak linear correlation with the sucrose distribution volume ( r=0.38, n=33, P<0.05). These results indicate that the initial distribution volume of glucose is more useful as an indicator of the central extracellular fluid volume status than the extravascular lung water.

The use of suppositories has been examined following a recent case in which an anaesthetist was reported to the United Kingdom General Medical Council. This study examined the preference for routes of administration of post-operative analgesia. A semi-structured interview with a written questionnaire was administered to 610 subjects (49 doctors; 62 nurses; 67 paramedical staff; 44 other hospital employees; 388 patients). Four hundred and fifty (74%) preferred the intravenous (i.v.) route, 24 (4%) preferred a suppository while 136 (22%) found either route acceptable. The i.v. route was most popular with young (98% under 20 years) females (79%) social class I subjects (90%), doctors (96%), nurses (95%), those who had never had a suppository (81%) and those who had ill effects following a previous suppository (95%). This result suggests that patients are more tolerant of suppositories than hospital staff but the majority prefer the i.v. route.

Ringer's solution expands blood volume by between 20% and 25% in awake volunteers, but little is known about its volume effect during general anaesthesia. In 35 men with a mean age of 70 years, the power of various intra-operative factors to change blood volume as estimated by the haemoglobin dilution method were analysed by multiple linear regression every 10 min during transurethral resection of the prostate performed under enflurane anaesthesia. The results show that blood volume increased by 60% of the infused Ringer's solution and by 35% of the irrigating fluid absorbed directly into the blood, while it decreased by slightly more than 100% of the bled volume. There was no correlation between systolic pressure and blood volume changes. This suggests that the volume effect of Ringer's solution in the blood is greater than generally believed during general anaesthesia.

A number of prospective randomized comparator studies have suggested that there is a reduction in post-operative nausea and vomiting following maintenance of anaesthesia with propofol compared with inhalational agents. We analysed these studies in more detail by examining the effects of induction agent, choice of inhalation agent, presence/absence of nitrous oxide, age of patient or use of opiate on the incidence of emesis. A search of the Zeneca database MEDLEY was undertaken and prospective randomized comparator studies identified. These were examined individually and independently by two of the authors and log-odds ratios, calculated from the incidence data of each individual trial, were determined and combined using a fixed-effects meta-analysis approach. Patients who received maintenance of anaesthesia with propofol had a significantly lower incidence of post-operative nausea and vomiting in comparison with inhalational agents regardless of induction agent, choice of inhalation agent, presence/absence of nitrous oxide, age of patient or use of opiate.

A double-blind randomized study was performed in 100 patients undergoing thyroidectomy to evaluate the effect of positive therapeutic suggestions made during neurolept-anaesthesia. The classic droperidol-fentanyl-N2O technique was used as these drugs preserve the neurophysiological functions required to process the information in the therapeutic suggestions given during general anaesthesia. Patients in the suggestion group heard positive non-affirmative suggestions during the whole operation. An autoreverse tape player was used. The control group listened to an empty tape. Both groups were comparable with respect to demographic variables, anaesthetic technique, drug dosage, duration of anaesthesia and surgery. Patients in the suggestion group suffered significantly less from post-operative nausea or volumiting (suggestion: 47.2% vs. control: 85.7%) and required less anti-emetic treatment (suggestion: 30.6% vs. control: 68.6%). We conclude that therapeutic suggestions heard during neurolept-anaesthesia are processed and decrease post-operative nausea and vomiting in patients after thyroidectomy.

The brachial plexus was identified by electrical stimulation before interscalene block with 30 mL 0.5% bupivacaine and adrenaline 1:200 000. During injection, compresion was applied with a finger proximal to the injection site. Spirometric measurements were made before the block, and then at 5 min, 10 min, 20 min and 4 h after the injection. Diaphragmatic excursion was measured radiographically before the block, and at 15 min and 4 h afterwards. In 25 patients studied, spirometric measurements decreased. Twenty minutes after the injection, the forced vital capacity was 27% less, forced expiratory volume at 1 s 34% less and peak expiratory flow rate 15% less (all P<0.05). Right diaphragmatic excursion decreased from 4.5 cm (SD 1.2 cm) to 1.8 cm (0.6 cm) at 15 mins and to 1.1 cm (0.6 cm) at 4 h (P<0.05). Identification of the plexus by electric stimulation combined with finger compression above the injection site did not prevent diaphragmatic paresis.

In a double-blinded study we examined the effect of supplementing patient-controlled morphine analgesia with intercostal nerve blockade to identify if this improved analgesia and reduced morphine requirements following renal transplantation. Fifty patients were randomized to receive unilateral intercostal nerve block with either 0.5% bupivacaine or saline to the lower five intercostal nerves. Each block was performed on the side of surgical incision following the completion of surgery. Patients receiving bupivacaine blockade reported reduced pain scores and used less morphine in the initial 4 h following renal transplantation, but did not demonstrate a significant reduction in overall pain scores, total 24 h morphine requirements, or sedation scores. Two patients developed a pneumothorax, neither of which were clinically apparent at the time of diagnosis, and only detected by chest radiography. A chest radiograph should therefore be considered mandatory after intercostal nerve blockade.

Ten patients, predicted to pose a difficult intubation of the trachea, underwent inhalational induction of anaesthesia using sevoflurane. In all 10 cases the airway was secured successfully and the patient proceeded to have the planned operation. In six of the cases the anaesthetist experienced a problem during the induction but in no case did this present any real difficulties or lead to a critical incident. We feel that sevoflurane has a place for inhalational induction in this challenging group of patients.

This study was undertaken to investigate the neuromuscular blocking profile and cardiovascular effects of Org 9487, a new aminosteroidal, non-depolarizing, neuromuscular blocking agent structurally related to vecuronium, in anaesthetized animals and in isolated muscle preparations. In in vitro functional assays of neuromuscular blocking activity, Org 9487 was between eight and 15 times less potent than vecuronium. In cats and monkeys the potency of Org 9487 was approximately one-seventh and one-twentieth, respectively, that of vecuronium. In both species, Org 9487 induced rapidly developing (onset times between 1.5 min and 1.9 min) neuromuscular paralysis, which was shorter-lasting than that of vecuronium and similar in time course to suxamethonium. The vagal: neuromuscular blocking dose ratio for Org 9487 was 3 and ganglion block was seen only at approximately 20 times the neuromuscular blocking dose. There was no evidence in the rat that Org 9487, administered at doses up to 3mg kg−1, inhibited noradrenaline re uptake. In anaesthetized dogs, Org 9487 (3 × 90% blocking dose) induced only relatively small and transient haemodynamic effects. The administration of clinically relevant doses of neostigmine or pyridostigmine shortened the time–course profile of Org 9487, even when administered during profound neuromuscular block. In animals, Org 9487 is a low potency, nondepolarizing neuromuscular blocking agent with a time course profile similar to that of suxamethonium. Although Org 9487 is less selective than vecuronium for the neuromuscular junction, it is unlikely to produce prohibitive cardiovascular side effects in man.

The direct cardiac effects of morphine, alfentanil, ketamine, etomidate, thiopentone, midazolam and propofol were measured in isolated Wistar rat hearts. Experiments were performed using a multiple conlumnar Langendorff apparatus and the hearts were perfused with a modified Tyrode solution under constant pressure. Each drug was applied from a different column in rising concentrations at 5-min intervals. Dose ranges were chosen to compare effects at sub-clinical, clinically relevant and more than clinical concentrations. Six rat hearts were chosen at random for each drug. Only thiopentone reduced contractile force at a clinically relevant concentration: measured as g contractility per g heart weight−1 (mean±standard deviation), base-line contractility was 8.8±2.4, and contractility at 10−4 mol litre−1 thiopentone was 7.1±1.5 (P<0.01). Alfentanil was the only drug to have no significant effect on the isolated heart at any concentration. Propofol was not cardiodepressant at clinically relevant concentrations, but had a lower therapeutic range than the other drugs.

The contractile response of smooth muscles to spasmogens can be divided into two components by modifying the extracellular Ca2+ concentration. The phasic component depends on the mobilization of Ca2+ from intracellular stores whereas the tonic component depends, to a large extent, on the influx of extracellular Ca2+. The present study was designed to investigate the effect of ketamine on the tonic response to carbachol or histamine in the guinea pig trachea. Tracheal spirals from female guinea pigs were mounted in organ baths filled with aerated physiological buffer, and their isometric tension was measured. The phasic response to 10−7m carbachol or 10−5m histamine in Ca2+ -free, ethylene glycol-bis(β-aminoethyl ether)-N, N,N',N'-tetraacetic acid-containing buffer and the tonic response to each spasmogen after restoring [Ca2+] in the buffer was measured in the absence or presence of ketamine. In the presence of normal physiological buffer, ketamine decreased the contractions induced by carbachol or histamine in a dose-dependent fashion. No measurable phasic response to either carbachol or histamine was obtained in our preparation. Ketamine (5 × 10−5m−10−3m) reduced the tonic response to 10−7m carbachol to 79.5±2.7−4.3±0.7% of the response without ketamine. Similarly, ketamine (5 × 10−4m−2 × 10−3m) decreased the tonic response to 10−5m histamine to 80.7±3.9−23.0±3.2% of the response in the absence of ketamine. Our findings support the hypothesis that ketamine inhibits the paracrine agent-induced contractions of smooth muscles by interfering with the influx of extracellular Ca2+ or with an intracellular event(s) requiring extracellular Ca2+.

We report a case of post-operative rhabdomyolysis following transmandibular buccopharyngectomy without reconstruction in a patient remaining in the supine position throughout the procedure. Muscle compression induced by a cushion used during the procedure had probably contributed to the rhabdomyolysis. Outcome was favourable without acute renal failure. Prevention, early diagnosis and treatment are the keys to a successful recovery.

A 17-year-old victim of a road traffic accident presented. Following investigation diagnoses of fractured first cervical vertebra, aortic transection, diffuse cerebral oedema, fractured right ribs 2–4 and pubic rami were made. Management of this case presented a number of anaesthetic dilemmas: management of the airway, use of cross-clamp vs. shunting or heparinization and bypass, cardiovascular and neurological monitoring, maintenance of cardiovascular stability during and post cross-clamp, minimizing the risk of post-operative renal and neurological dysfunction.

This paper describes two otherwise unrelated cases of fatal haemopericardium resulting directly from attempted cannulation of the right subclavian vein. Although this is an extremely rare complication, it is essential that all physicians involved in establishing central venous access are aware of the danger of causing this condition, and how the use of a careful technique of insertion can minimize the risk.