A non-invasive ultrasound imaging technique (BladderScan) was used prospectively in an attempt to reduce the need for catheterization of the urinary bladder and the incidence of urinary tract infections after orthopaedic surgery. Over a 4-month period, in which 1920 patients were included, catheterization was performed if there was no spontaneous diuresis by 8 h after surgery. A total of 31% of these patients were catheterized, and 18 patients developed urinary tract infections. In a subsequent 4-month period, there were 2196 patients, catheterization was performed only if the bladder volume was more than 800 mL 8 h after surgery. The rate of catheterization decreased to 16%, and five patients developed urinary tract infections. In our patients, measuring bladder volume reduced the need for a urinary catheter and the likelihood of urinary infection.

Following administration of 0.6 mg kg−1 rocuronium, the pharmacokinetics and the pharmacodynamics were studied in six obese and six control (normal weight) patients receiving balanced anaesthesia. Twelve gynaecological patients were allocated into two groups, according to body mass index (normal weight: body mass index: 20–24, obese weight: body mass index > 28). Venous plasma concentrations were determined by high-pressure liquid chromatography before administration of rocuronium, at 1, 2, 4, 6, 8,10, 15, 20, 25, 30, 35, 40, 48, 60, 75, 120, 180, 240, 300, 360 and 420 min after administration of rocuronium and at recovery of single twitch to 25% and 75% of control twitch height. Onset time was shorter (NS) in the obese compared with normal weight (obese weight: 65 ± 16, normal weight: 100 ± 39 s, mean±SD). Duration 25% (obese weight: 29.5 ± 5.3, normal weight: 28.4±5.3 min) and spontaneous recovery time (obese weight: 12.6 ± 2.7, normal weight: 12.5 ± 2.3 min) did not show any differences between the two groups. The pharmacokinetics of rocuronium were comparable in the two groups. The volume of distribution at steady state Vss (mL kg−1) was 208 ± 56 in normal weight and 169 ± 37 in obese weight. Distribution (T1/2α) and elimination half-life (T1/2β) as well as mean residence time were 15.6 ± 3.7, 70.3 ± 23.9 and 53.2 ± 9.8 min in normal weight and 16.9 ± 3.8, 75.5 ± 25.5 and 51.1 ± 18.9 min in obese weight,respectively. Also, no differences were observed in plasma clearance (3.89 ± 0.58 in normal weight and 3.62 ± 1.42 mL kg−1 min−1 obese weight). This study indicates that the pharmoacodynamics and pharmacokinetics of rocuronium are in female patients not altered by obesity.

A study of 56 patients was undertaken to determine whether there is a difference in the effect of the laryngeal mask airway and the endotracheal tube on the vocal tract after short-duration anaesthesia. All the patients were interviewed pre- and post-operatively.In 43 patients, it was possible to assess the larynx using videoendoscopy and videostrobolaryngoscopy both pre- and post-operatively. Selected acoustic characteristics were investigated in 51 patients pre- and 18–24 h post-operatively. Thirty-four patients that did not have anaesthesia were used as an age-matched control.

The interview showed, that patients in the LMA group complained less frequently of having post-operative complained less frequently of having post-operative demonstrated minor lesions of the vocal tract in six patients in the ETT group and in one patient in the LMA group. Of the 12 voice variables evaluated, there was no significant difference in any parameter between the two groups. Both groups had a higher fundamental frequency post-operatively.

The efficacy of anaesthetic premedication has been assessed using sedative scores or a visual analogue scale. However, in both it may be difficult to exclude evaluators’ subjectivity or a placebo effect. Plasma concentration of catecholamines may also be useful for the assessment of patient anxiety. Recently bispectral electro-encephalographic analysis has been developed, and the bispectral index monitor has been reported to give measurements which correlate well with the depth of sedation. In the present study, we have examined the relation between bispectral index values and plasma catecholamine concentrations after oral diazepam premedication. Twenty-eight patients scheduled for elective surgery were randomly assigned to one of two groups: diazepam premedication group (group D(+), n=14) and no premedication group (group D(−), n=14). The patients were premedicated orally with diazepam 10 mg and roxatidine 75 mg in group D(+), and with roxatidine 75 mg only in group D(−) 90 min before arrival in the operating theatre. After patients arrived in the operating theatre, the bispectral index monitor was applied. Venous blood samples(6 mL) were collected in the case of patients in group D(+) for the measurement of plasma catecholamines levels using high-performance liquid chromatography. The bispectral index level (mean±SD) in group D(+): 93.5±773.5 was significantly lower than that in group D(−): 96.1±1.8(P<0.05). There was a significant correlation between bispectral index and plasma norepinephrine levels (r=0.567, P<0.05). The present study suggests that the bispectral index monitor may detect the effect of oral diazepam premedication.

We investigated the effects of controlled hypotension with haemodilution under isoflurane anaesthesia on splanchnic perfusion in elderly patients. We determined the intramucosal pH using gastric tonometry in 28 patients scheduled for hip surgery. Patients without cardiac disease were assigned to two groups according to age. Group A (adult patients, n=14) included patients aged less than 60 years (range 29–58 years, 47±11 years, mean±SD) and group B(elderly patients, n=14) more than 65 years (68–78 years, 72±5 years). Anaesthesia was maintained with N2O-O2-isoflurane. After induction of anaesthesia, haemodilution was produced by drawing 800–1000 mL of blood and replacing it with the same amount of hydroxyethyl starch. Final haematocrit values were 23–24% in all groups. Controlled hypotension was induced with prostaglandin E1 (PGE1) and mean blood pressure was maintained at approximately 60 mmHg for approximately 80 min. Measurements, including gastric intramucosal pH (pHi), arterial blood pH (pHa) and serum lactate were measured before haemodilution (T0), after haemodilution (T1), 80 min after starting hypotension (T2), 60 min after recovery from hypotension (T3) and on the 1st post-operative day (T4). The values of pHa and lactate showed no change in the groups throughout the time course. The gastric pHi values showed significant decreases from 7.418±0.035 to 7.334±0.024 (P < 0.05) in group A and from 7.428±0.029 to 7.320±0.039 (P < 0.05) in group B after haemodilution, while no further decreases were found at 80 min after starting the hypotension (7.329±0.038 in group A and 7.322±0.031 in group B) and 60 min after recovery from hypotension (7.331±0.029 in group A and 7.328±0.034 in group B). It can be concluded that moderate haemodilution under isoflurane anaesthesia might impair splanchnic perfusion in adult and elderly patients. The addition of controlled hypotension with PGE1 or an increase in age did not further impair splanchnic perfusion nor the splanchnic oxygen supply.

In a Swedish nation-wide study, 1196 members of the general public, and 121 physicians and 339 nurses drawn from 29 intensive care units were questioned about the use of ventilator treatment for severely ill patients. Response rates were 64%, 88% and 86%, respectively. Two typical case history scenarios were presented: one describing a conscious and competent patient with pneumonia and severe cancer, and the other describing a patient who had been comatose for 1 month following head trauma. In the case of the cancer patient, 49% of the general public, 63% of the physicians and 59% of the nurses answered that theywould wish that the ventilator treatment be discontinued, if they were the patient. In the case of the comatose patient, 48% of the general public, 82% of the physicians and 70% of the nurses answered that they would wish that the ventilator treatment to be discontinued, if they were a relative of the patient. Respondents own preferences, in the three groups,for life support favoured withdrawal of ventilator treatment.

To evaluate arterial (PaCO2), end-tidal (PETCO2) and carbon dioxide tension difference during mechanical ventilation with extratracheal airways, 60 patients ASA physical status I-II, receiving general anaesthesia for minor extra-abdominal procedures were randomly allocated to receive either a cuffed oropharyngeal airway (group COPA, n=30) or a laryngeal mask (group LMA, n=30). The lungs were mechanically ventilated by IPPV using a 60% nitrous oxide and 1–1.5% isoflurane in oxygen mixture (VT8 mL kg−1; RR=12 b min−1; I/E=1/2). After PETCO2 had been stable for at least 10 min after airway placement, haemodynamic variables and PETCO2 were recorded and an arterial blood sample was obtained for measurement of PaCO2. No differences in anthropometric parameters, smoking habit, haemodynamic variables and incidence of untoward events were observed between the two groups. Airway manipulation, to maintain adequate ventilation, was required in only nine patients in the cuffed oropharyngeal airway group (30%)(P < 0.0005); however,in no case was it necessary to remove the designated extratracheal airway due to unsuccessful mechanical ventilation. The mean difference between arterial and end-tidal carbon dioxide partial pressure was 0.4±0.3 KPa in the laryngeal mask group (95% confidence intervals: 0.3–0.5 KPa) and 0.3±0.26 KPa in the cuffed oropharyngeal airway group (95% confidence intervals: 0.24–0.4 KPa) (P =NS). We conclude that in healthy adults who are mechanically ventilated via the cuffed oropharyngeal airway, the end-tidal carbon dioxide determination is as accurate an indicator of PaCO2 as that measured via the laryngeal mask, allowing capnometry to be reliably used to evaluate the adequacy of ventilation.

Intensive care patients with organ failure often suffer an acute catabolic state. Leptin is a 16-kDa hormone which is produced by mature adipocytes and correlates with human energy expenditure. We investigated whether continuous venovenous haemofiltration, which may eliminate molecules up to 20–30 kDa, is capable of removing human leptin. Leptin measurements were made in the plasma of 15 patients with sepsis before continuous venovenous haemofiltration (T0) and during the procedure at 24 h (T1), 48 h (T2), and 72 h (T3), using samples taken before and after haemofiltration. In addition, measurements were made in the ultrafiltrate at T1–T3. The plasma leptin level at T0 was 17.6 ng mL−1. The concentration at T1 was 17.5 ng mL−1 pre-filter and 26.5 ng mL−1 post-filter (T2: 14.2/23.2 ng mL−1; T3: 12.4/16.3 ng mL−1).This concentration effect after haemofiltration was also seen with albumin. The values measured at T3 tended to be lower than those recorded at T1. The mean leptin levels in the ultrafiltrate were 0.15–0.18 ng mL−1. The range of leptin levels in the ultrafiltrate was thus only 0.5–3% of that measured in plasma. We conclude that human leptin is only minimally elimininated into the ultrafiltrate by continuous venovenous haemofiltration and that plasma leptin levels may decrease during sepsis.

An increase of more than 50% in cerebral blood flow velocity in the middle cerebral artery was recently reported in hypocapnic volunteers, while inhaling 50% nitrous oxide. We measured cerebral blood flow velocity in the middle cerebral artery in 10 anaesthetized hypocapnic (ETCO2=25 mmHg) patients with brain tumours while administering increasing concentrations of nitrous oxide. At an end-tidal concentration of 50% and 70% nitrous oxide in oxygen, neither mean arterial pressure (base-line: 84±8 mmHg vs. (50% nitrous oxide): 82±9 mmHg and (70% nitrous oxide): 80±8 mmHg) nor cerebral blood flow velocity in the middle cerebral artery (base-line: 32±7 cm s−1 vs. (50% nitrous oxide): 34±8 cm s−1 and (70% nitrous oxide): 34±9 cm s−1) changed significantly. The data from our clinical investigation indicate that administration of increasing concentrations of nitrous oxide to already anaesthetized and hypocapnic patients does not change cerebral blood flow velocity in the middle cerebral artery.

Monocytes play a very important part in humoral as well as in cell-mediated immunity. At present, however, the knowledge of the influence of anaesthetic agents on the functions of monocytes is limited. In the present study, the effects of thiopentone, methohexitone, ketamine, midazolam, droperidol, propofol, etomidate, and fentanyl on monocyte chemotaxis were examined in vitro using a 48-well microchemotaxis chamber. Clinically relevant concentrations of ketamine, midazolam, and droperidol significantly (P≤0.05) inhibited chemotaxis. For that reason, it is possible that these anaesthetics impair the immunological system in vivo. This possibility should be further examined.

We determined the effects of pretreatment with midazolam or fentanyl on the ease of laryngeal mask airway insertion using propofol without a muscle relaxant. One hundred and eighty ASA class I or II patients were randomly allocated to one of three groups, 60 patients per group, to receive either placebo (Group C), midazolam 0.05 mg kg−1 (Group M) or fentanyl 2 μg kg−1 (Group F), respectively. Following intravenous administration of these drugs, Group C received propofol 2.5 (Group C-2.5) or 3.0 mg kg−1 (Group C-3.0). Group M and Group F received propofol 2.0 or 2.5 mg kg−1 (Group M-2.0, M-2.5, F-2.0 and F-2.5, respectively). There was a smaller incidence of severe head and limb movements on LMA insertion in Group M-2.5, Group F-2.0 and Group F-2.5 than in Group C-2.5. Airway obstruction and inadequate jaw relaxation, which were occasionally recognized in Group C and Group F patients, were not observed in Group M-2.5. Overall the ease of LMA insertion was significantly better in Group M-2.0, Group M-2.5 and Group F-2.5 than in Group C 2.5, however, the blood pressure in Group F after LMA insertion was significantly lower than in Group M. We conclude that pretreatment with midazolam 0.05 mg combined with propofol 2.5 mg kg−1 provides safe and satisfactory conditions for LMA insertion.

The post-operative anti-emetic efficacy of 4 and 8 mg of ondansetron in adult patients with and without a previous history of motion sickness (PHMS) was assessed by meta-analysis. MEDLINE and EMBASE databases were searched for randomized placebo-controlled trials evaluating the anti-emetic effectiveness of ondansetron in a 24-h period. In the 49 studies found, a further selection was with respect to those studies that noted the patient's previous history of motion sickness. Twelve trials involving 2122 patients; 446 previous history of motion sickness(+)patients and 1676 previous history of motion sickness(−) patients met the selection criteria. The dose of 4 mg ondansetron was 71.5% more effective in previous history of motion sickness(+) than in previous history of motion sickness(−) patients. For the 8 mg dose, the odds ratios (95% CI) were: previous history of motion sickness(+)=3.11 (1.40–6.93) and previous history of motion sickness(−)=2.08 (1.35–3.21). The calculated number needed to treat was also more favourable in previous history of motion sickness(+) patients for both doses of ondansetron,demonstrating a higher effectiveness in this subgroup of patients.

Several studies have demonstrated that pre-operative fasting may be as short as 2 h for clear fluids and 6 h for solids with no adverse effect on volume or pH of gastric contents. Other studies suggest that many patients do not receive pre-operative prescribed medications. One hundred and fifty-three adults presenting for elective surgery (mean age 51 years) were studied to assess fasting practice. Fasting times far in excess of the recommended safe minimum were found. Mean length of fast for solids was 15 h 24 min (95% confidence intervals±49 min) and for fluids 12 h 30 min (95% confidence intervals±30 min). Of the 53 patients taking regular medications, 23 did not receive one or more drugs pre-operatively; most notably 45% of cardiac prescriptions were not administered. Despite strong evidence to support a change, actual practice continues to fall below accepted standards.

We report a case of accidental intra-arterial injection of propofol in a 30-year-old woman admitted for curettage. The patient reported pain, which was followed by a hyperaemic area of 6 × 7 cm around the injection site. Later a blanching of the distal part of the hand was noticed, lasting for 3 min. When pain appears during propofol administration, an intra-arterial injection must be excluded.

A 72-year-old woman had a minitracheostomy inserted for sputum retention. This was undertaken by a relatively junior resident who opted to use an early model minitracheostomy kit Minitrach II. The following day the patients condition deteriorated and intubation was warranted, at which time it was apparent to senior staff that the minitracheostomy had been malpositioned. Ten days later, formal tracheostomy was performed under general anaesthesia. After incision,an abscess in the thyroid gland was found. Histology subsequently revealed a Hurthle cell tumour of the thyroid. Thyroid abscess is exceedingly rare. It typically occurs in abnormal thyroid tissue and with a focus on infection. The combination of Hurthle cell adenoma and a foreign body (the minitracheostomy) was evidently causative in this instance. This complication of minitracheostomy insertion has not to our knowledge, previously been reported.

An 85-year-old man with undiagnosed eventration of the left hemidiaphragm had an above-knee amputation under epidural anaesthesia. His post-operative course was stormy with two episodes of cardiovascular collapse. On the third post-operative day, rupture of the left hemidiaphragm was diagnosed, the bowel had herniated into the left hemithorax. It is proposed that the left hemidiaphragm ruptured spontaneously because of muscular weakness secondary to the thoracic segmental blockade associated with lumber epidural anaesthesia.