For supportive therapy in sepsis, an adequate volume loading is likely the first step, and possibly the most important step in the treatment of patients with septic shock. However, it is still a matter of debate what kind of fluids, endpoints for resuscitation and monitoring techniques should be used. Nevertheless, therapies which closely control volume loading and regional perfusion are becoming more utilized. An elevated global O2-supply (DO2) may be necessary and beneficial in most of these patients but the increase of DO2 should be guided by the measurement of parameters assessing global and regional oxygenation. Routine strategies for elevating DO2 by the use of very high dosages of catecholamines cannot be recommended. Vasopressors should be used to achieve an adequate perfusion pressure. With norepinephrine, no negative effects on regional perfusion have been demonstrated when the patient is adequately volume resuscitated and the DO2 is normal or even slightly elevated. In contrast, epinephrine should be avoided because it seems to redistribute blood flow away from the splanchnic region. There is controversy whether dopamine should still be used as a first-line drug in patients with septic shock, because there are some clinical and experimental data that indicate unfavourable effects on mucosal perfusion of the gut.

To date, there are no convincing data to support the routine use of low-dose dopamine or dopexamine in patients with sepsis. Neither low-dose dopamine nor dopexamine have been proven to prevent renal failure in septic patients. Furthermore, there is evidence that low-dose dopamine may reduce mucosal perfusion in the gut in some patients. Dopexamine has been suggested to improve splanchnic perfusion but because these effects remain somewhat controversial, there is as yet no reason for a general recommendation for dopexamine in septic patients.

These recommendations are currently limited by the lack of sufficient outcome studies and studies which evaluate regional perfusion. Until the various catecholamine regimes are more fully examined, recommendations for catecholamine support in sepsis must be considered ‘conditional’.

The disposition of propofol in the blood and brain of New Zealand rabbits was studied in three groups of six rabbits. One group received a single anaesthetic dose; a second group received a 1-h infusion; and a third group was studied after the rabbits were judged to have recovered from a 1-h infusion. There was a high concentration of propofol in the red blood cell fraction and in the brain, however, the red blood cell concentration largely exceeded the one found in the brain in all groups of animals. This is consistent with the high fat solubility of diisopropylphenol. The possible effects of propofol sequestered in red blood cells is discussed.

In a multicentre, randomized, double-blind, placebo-controlled dose-ranging study, 1030 patients undergoing outpatient surgery with general anaesthesia received i.v. dolasetron mesylate (12.5, 25, 50, or 100 mg) or placebo. The principal outcome measure was the proportion of patients who were free of emesis or rescue medication for the 24-h period after the study drug was given; the subsidiary outcome measure was survival time without rescue medication. Effects on nausea were quantified using a visual analogue scale. Compared with placebo, a complete response was significantly higher when all four dolasetron doses were combined (49% vs. 58%, P = 0.025). In females, dolasetron, 12.5-mg, dolasetron provided maximum clinical benefit (effectiveness compared with adverse events), with no additional benefit in complete response rates or nausea visual analogue scale scores at higher doses. No significant differences were observed in complete response for any dolasetron dose in males compared with placebo. The majority of adverse events reported were mild or moderate. Dolasetron provided well-tolerated, safe, and effective prophylaxis for post-operative nausea and vomiting with maximum effectiveness observed at a dose of 12.5 mg.

A survey was constructed to ascertain the views of The Royal College of Anaesthetists tutors regarding the acceptability of inhalational induction with sevoflurane for emergency anaesthesia. A questionnaire was sent to all tutors asking them to indicate their preferred choice of anaesthetic technique, and whether they believed inhalation induction with sevoflurane to be acceptable, in each of four scenarios: acute epiglottis; bleeding after tonsillectomy; appendicitis; and laparotomy in the shocked patient. Two hundred and sixty-two (89%) completed questionnaires were received from 294 college tutors. We have shown that the majority of The Royal College of Anaesthetists tutors would use sevoflurane for patients with an acutely compromised airway. One in four college tutors would accept the use of sevoflurane for a shocked patient for laparotomy. Anaesthetists who manage critically ill patients with an inhalational induction should be reassured by the fact, that a significant proportion of their colleagues would find this technique acceptable.

A number of methods exist by which the pH of local anaesthetic solutions may be increased. Most commonly, these require the addition of differing amounts of sodium bicarbonate solution according to the local anaesthetic drugs. Sodium bicarbonate (1%) was titrated against pH in six commonly used local anaesthetic solutions. Titration curves of pH and volume of sodium bicarbonate solution added are shown for this group of local anaesthetics. This study demonstrates that 1 mL of 1% sodium bicarbonate solution may be used to alkalinize this range of local anaesthetics without the risk of precipitation. We also conclude that Ropivacaine (at concentration 0.75% and 1.0%), is unsuitable for alkalinization since it precipitates at a pH of 6.0.

In order to prescribe appropriate analgesia for burns dressing changes the pain experienced by 30 burned patients during this procedure was recorded. Patients received analgesia prior to their dressing changes according to the current protocol in the burns unit. During the same period the medical and nursing staff in the unit who were involved in prescribing and administering the analgesia for the dressing change, were asked to assess the severity of pain that they thought patients experienced during dressing changes. Patients recorded their worst pain as none or mild in 64% of procedures. In contrast, no surgeon and only one nurse, rated pain as none or mild. The discrepancy between severity of pain recorded by patients and the pain predicted by staff prescribing and administering analgesia has clinical implications.

We evaluated the ability of inexperienced personnel in using a prototype illuminated flexible catheter to assist tracheal intubation through the intubating laryngeal mask in anaesthetised, paralysed patients. The device consists of a completely flexible thin plastic catheter, a bulb attached to its distal end and a 15-mm concentric adapter at its proximal end. The illuminated catheter is placed into a straight silicone tracheal tube in such a way that the bulb is placed at the distal end of the tracheal tube. Six nurses inexperienced in tracheal intubation followed a 2-hr training program by using the device through the intubating laryngeal mask in a mannequin and then intubated 10 patients each, with instruction from an anaesthetist. All patients (n = 60) were ASA 1–2, scheduled to undergo general anaesthesia for elective surgery. After fentanyl/propofol induction the intubating laryngeal mask was inserted. When an adequate airway was established, patients received atracurium and the endotracheal tube preloaded with the device was inserted through the intubating laryngeal mask and by observing the glow in the neck was advanced into the trachea. The final outcome and the duration of the procedure were recorded. The intubating laryngeal mask was inserted successfully in all patients. The success rate of intubation was 57/60 (95%); 38 patients at first attempt and 19 after two or three attempts. The mean (±SD) duration of the procedure in the first five patients in the series of each nurse was 74±40 s while in the last five patients it was diminished to 52±23 s (P= 0.01). We conclude that the described methodology has the potential for more widespread use of tracheal intubation through the intubating laryngeal mask even by inexperienced personnel.

The effects of intravenous and epidural clonidine, 4 μg kg−1, combined with epidural morphine, 40 μg kg−1, on the neuro-endocrine and immune stress responses to thoracic surgery are reported. A control group received only epidural morphine. Anaesthesia was induced and maintained with propofol. Catecholamines, vasopressin, cortisol, β-endorphin concentrations and leucocyte counts were measured before drug administration, immediately after intubation of the trachea, after thoracotomy and at the end of surgery. Catecholamines did not change in any of the groups. The other stress hormones increased during surgery, the pattern being similar in the three groups. Total leucocyte and neutrophil counts were increased in all groups at the end of surgery, but the increase was least in the epidural clonidine group. The number of lymphocytes was reduced at the end of surgery in the epidural and intravenous group, compared with the control group in which the number of lymphocytes did not change. The effects are more pronounced with epidural than with intravenous administration. We conclude that clonidine can modulate the immune stress response to thoracic surgery.

The effects of propofol on mean arterial pressure, heart rate and Aδ and C somatosympathetic reflexes, recorded in renal nerves, evoked by repeated individual supramaximal electrical stimuli applied to radial nerves, were observed in anaesthetized, paralysed and artificially ventilated dogs. Propofol was infused at rates from 0.4 to 2.0 mg kg−1min−1. Mean C and Aδ reflexes were abolished at plasma concentrations (mean, SEM) of 24.3 (3.3) and 29.2 (2.6) μg mL−1 (P < 0.05), respectively, when mean arterial pressure and mean heart rate were reduced by approximately 55% (P < 0.01) and 26% (P > 0.05), respectively. Recovery of Aδ and C reflexes occurred at plasma concentrations of 13.1 (2.3) and 9.9 (1.3) μg mL−1 (P > 0.05), respectively. There was a logarithmically linearly related fall in mean arterial pressure by 70% up to a plasma concentration ≈97 μg mL−1 (r2=0.7) with a 28% reduction in heart rate which was uncorrelated with the plasma concentrations (r2=0.12). In conclusion, propofol abolished Aδ and C responses at comparable plasma concentrations and caused a major reduction in both mean arterial pressure and heart rate which is consistent with resetting of the baroreflexes. The reduction in mean arterial pressure was logarithmically, linearly correlated with a progressive increase in plasma concentrations without evidence of a ceiling effect.

Dexamethasone decreases chemotherapy-induced emesis when added to an antiemetic regimen. This study was undertaken to evaluate the efficacy of granisetron/dexamethasone combination for preventing postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy (LC). In a prospective, randomized, double-blind manner, 120 patients (83 females), aged 25–65 years, were assigned to receive granisetron 40 μg kg−1 alone or granisetron 40 μg kg−1 plus dexamethasone 8 mg (n=60 of each) intravenously immediately before the induction of anaesthesia. A standardized general anaesthetic procedure and postoperative analgesia were used. A complete response, defined as no PONV and no need for another rescue antiemetic, during 0–3 h after anaesthesia was 83% with granisetron and 98% with granisetron plus dexamethasone, respectively (P=0.008); the corresponding incidence during 3–24 h after anaesthesia was 83% and 98% (P=0.008). No clinically important adverse events were observed in any of the group. In conclusion, prophylactic therapy with granisetron/dexamethasone combination is more effective than granisetron alone for the prevention of PONV after LC.