Recovery of neuromuscular blockade after vecuronium 0.2 mg kg−1 was measured by post-tetanic burst count (PTBC) and train-of-four (TOF) in 120 adult patients anaesthetized by one of four techniques: neuroleptanaesthesia or one minimum alveolar concentration of isoflurane, enflurane, or sevoflurane. Onset of recovery was taken when there was reflex movement in response to carinal stimulation. The time course of recovery measured by burst count was similar for all four types of anaesthesia. Recovery of each of the twitches of the TOF was significantly shorter under neuroleptanaesthesia than under isoflurane, enflurane, or sevoflurane anaesthesia [times to return of T1 were 41.4±5.4, 51.5±10.6, 52.2±10.0, or 55.3±11.2 min (mean±SD). P<0.05]. The burst count at the onset of reflex movement was less under neuroleptanaesthesia than under isoflurane, enflurane, or sevoflurane anaesthesia (16.3±4.8, 26.7±6.7, 27.7±6.8, 28.0±8.4, P<0.05). The ratio of first twitch to control twitch at the onset of reflex movement was the same for all four types of anaesthesia.

Prolonged nerve conduction blockade has been proposed to result from the summed effects of charged and neutral local anaesthetics. Thirty-seven patients were randomly allocated to receive intravenous patient-controlled analgesia alone or combined with intercostal blockade (T7–T11) with a mixture of 0.45% bupivacaine and 0.6% phenol for post-cholecystectomy analgesia. Adequacy of pain relief was measured by patient scores on a 10-cm visual analogue scale and by dose–demand ratio, amounts of loading dose and total consumption of morphine and also the duration of patient-controlled analgesia in each group. No differences were found between groups in post-operative scores, dose–demand ratios and loading doses of morphine. However, in the combined treatment group, a significantly lower total consumption of morphine (P<0.05), associated with a shorter duration of patient-controlled analgesia (P<0.02) and a decreased mean number of unsuccessful demands (P<0.001) were recorded. Intercostal blockade with bupivacaine–phenol supplements intravenous patient-controlled analgesia for post-cholecystectomy pain relief.

Hypoventilation as a consequence of deep intravenous sedation is the most frequently reported cause of cardiac arrest during upper gastrointestinal endoscopy (UGIE). Haemodynamic stress can contribute to myocardial ischaemia; therefore, this study was designed to observe prospectively the cardio-respiratory changes during UGIE using either midazolam or propofol for conscious sedation. Thirty-four patients, aged 50 years and older, ASA physical status I–III, scheduled for elective UGIE with sedation, were studied. Oxygen saturation, heart rate, non-invasive blood pressure and Holter ECG were recorded continuously starting 15 min before sedation until 15 min after the endoscopy. In addition, plasma catecholamine concentrations were determined. The results of this study are consistent with previous reports that cardiopulmonary events may occur during endoscopy, with or without sedation. Both midazolam and propofol sedation may provide some protection against haemodynamic stress in response to insertion and manipulation of the endoscope, but sedation can also contribute to the occurrence of hypoxaemia.

In a prospective, randomized, double-blind study, we compared intravenous tenoxicam with rectal diclofenac for post-operative pain relief after day case arthroscopy or laparoscopic sterilization. Intravenous tenoxicam (40 mg) was administered as a single bolus at induction, or rectal diclofenac (100 mg) was administered immediately after induction. Both groups were similar with respect to age, weight, sex of the patients, the operation performed and the operative time. There were no significant differences observed between the groups for pain scores at 30 min, 60 min and 24 h post-operatively. The time to first analgesic requirement, the dose of pethidine administered and total analgesic requirements in the first 24 h post-operatively were equivalent in both groups. In view of the similar efficacy of both of these drugs, patient preference and ease of administration, the use of tenoxicam is appropriate in many patients undergoing day case surgery.

Axillary brachial plexus block using 20 mL of 0.75% ropivacaine or 2% mepivacaine was compared in a prospective, randomized, double-blind study of two groups of 15 patients. The times to onset of sensory and motor block and to resolution of motor block, as well as the time to onset and degree of post-operative pain were recorded by an observer blinded to the identity of drug. Times to onset of sensory block were similar in the two groups (ropivacaine 10 min, mepivacaine 8 min). Resolution of motor block in the operated hand and the time to first requirement of post-operative analgesia occurred later with ropivacaine (9 h 50 min and 10 h) than with mepivacaine (3 h 50 min and 6 h), P<0.01 for both measurements. Nine patients who received ropivacaine and two patients who received mepivacaine did not require further post-operative analgesia (P<0.05). Ropivacaine is less toxic than other long-acting local anaesthetics, and 0.75% ropivacaine may be better for brachial plexus block when fast onset is required and prolonged pain relief is useful.

Sevoflurane has been reported to generate oxygen free radicals. We have investigated whether sevoflurane or isoflurane enhances oxygen free radical formation in the post-ischaemic reperfused heart. An isolated rat heart–lung preparation was used. Thirty male Wistar rats were allocated to four groups: control, no drug, 2.5% sevoflurane and 1.4% isoflurane. The heart was perfused initially at a cardiac output of 30 mL min−1 and a mean arterial pressure of 70 mmHg. Ten minutes after the start of perfusion, the heart was rendered globally ischaemic for 10 min by reducing the preload and afterload to zero. Then, the heart was reperfused for 10 min. At the end of reperfusion, the heart was freeze dried for 6 days. The perfusate blood was collected just before and just after ischaemia and at the end of reperfusion. The formation of hydroxyl radicals in perfusate blood and heart was measured with high-performance liquid chromatography using salicylic acid. Hydroxyl radicals react with salicylic acid, yielding 2,3-, 2,4-, 2,5- and 3,4-dihydroxybenzoic acid (DHBA). Before and after ischaemia, there were no significant differences in cardiac output, systolic pressure, heart rate and right arterial pressure among the groups. The concentrations of 2,3-, 2,4-, 2,5- and 3,4-DHBA in the perfusate blood after ischaemia and reperfusion were significantly higher than those before ischaemia in all groups. However, there were no differences in the DHBA levels among groups. This study indicates that sevoflurane and isoflurane do not enhance hydroxyl radical formation in the post-ischaemic reperfused heart.

The haemodynamic effects of anaesthesia with gamma-hydroxybutyrate (GHB)/sufentanil for elective coronary artery bypass grafting (CABG) were investigated and compared in patients with unimpaired left ventricular function (ejection fraction ≥45%, left ventricular end diastolic pressure ≤16 mmHg) and patients with impaired left ventricular function. In 38 consecutive patients scheduled for CABG (21 with unimpaired and 17 with impaired left ventricular function), anaesthesia was induced with etomidate, sufentanil and pancuronium. After tracheal intubation, the lungs were normoventilated (end tidal Pco2 4.9−5.6 kPa) with an oxygen-air mixture (Fio2 0.5). Total intravenous anaesthesia was maintained with GHB (20 mg kg−1 h−1after a ‘priming dose’ of 40 mg kg−1) and sufentanil (2 μg kg−1 h−1). Haemodynamic measurements were made after induction of anaesthesia and at various times in the prebypass period. Patients in both groups showed similar haemodynamic trends. Mean arterial pressure showed a maximum reduction of 10%, whereas heart rate and right- and left-sided filling pressures remained unchanged within the groups after the induction of anaesthesia. Cardiac index remained unchanged in both groups, although values differed between the groups. A total of 14 out of 21 patients (67%) with unimpaired and 10 out of 17 patients (59%) with impaired ventricular function required supplementary administration of opioids to control temporary hypertension after sternotomy. No episodes of myocardial ischaemia were detected during the study period using ST segment analysis (leads II and V5). The results of this study suggest that GHB provides adequate haemodynamic conditions in the prebypass period and may be a suitable agent for TIVA also in patients with impaired left ventricular function undergoing CABG.

Thirty-eight ASA I–III patients undergoing lower abdominal operations were randomly allocated to receive either morphine (group M, patient-controlled analgesia bolus=1 mg of morphine) or tramadol (group T, patient-controlled analgesia bolus=10 mg of tramadol) for post-operative patient-controlled analgesia (PCA) after receiving morphine intraoperatively. There were no between-group differences in the pain, sedation or vomit scores. The nausea scores were significantly higher in group T in the initial 20 h and between 32 and 36 h (P<0.01, 0–4 and 8–12 h; P<0.05, 4–8, 12–16, 16–20 and 32–36 h). The incidence of dizziness was also significantly higher in group T (68.4% vs. 31.6%, group T vs. group M, P<0.05). There was no difference in the overall satisfaction. We conclude that the use of tramadol, compared with morphine, for post-operative PCA after intraoperative loading with morphine is associated with more nausea and dizziness, but with similar sedation, quality of analgesia and patient satisfaction.

The clinical availability of artificial oxygen carriers (AOCs) would result in profound alterations in transfusion medical practice. Rapid progress in the scientific and technological development of AOCs has advanced to a critical stage at which safe and effective alternatives to the transfusion of red blood cells are emerging. Haemoglobin- and perfluorocarbon-based oxygen carriers are under current clinical investigation. Artificial oxygen-carrying solutions, by virtue of their acellular structure, can be used to transport oxygen to ischaemic tissues that cannot otherwise be reached by cellular blood components. Organs awaiting transplantation can be preserved for a long time after perfusion with AOCs and tumour susceptibility to chemo- and radiotherapy is increased. The use of AOCs is therefore not confined to their use as red blood cell substitutes, but may find a wide spectrum of interdisciplinary applications.

The cardiovascular effects of Org 9487 during isoflurane anaesthesia have been evaluated using three doses around its ED90 for neuromuscular blockade, i.e. 1 mg kg−1, 2 mg kg−1 and 3 mg kg−1. Heart rate increased to 110%, 115% and 118% in patients receiving 1 mg kg−1, 2 mg kg−1 and 3 mg kg−1 respectively. There were no significant effects on systolic and diastolic blood pressures for the two lower dose groups. Patients receiving Org 9487 3 mg kg−1 displayed significant decreases in systolic and diastolic blood pressures (91% and 82% of the control values respectively). Except for heart rate in the group receiving 3 mg kg−1, all measurements returned to baseline after a maximum of 15 min. Six patients experienced a transient increase in airway pressure after administration of Org 9487, which was accompanied by a decrease in oxygen saturation in two out of six subjects, but there was no audible wheezing. These episodes were self-limiting and required no treatment. There were no other adverse reactions to this drug during this study.

Fifty-five consecutive patients undergoing a short-stay ophthalmic operation (orbital hydroxyapatite implantation) were recruited over 1 year to assess the frequency and duration of post-operative nausea and vomiting over 7 days. The incidence of nausea and vomiting in hospital was recorded. Patients scored their nausea and vomiting four times daily at home. By the end of the first day after surgery, 31 (75%) patients had experienced mild to severe nausea. Eighteen (38%) patients became nauseated on five or more occasions. Nineteen (35%) patients had vomited by the end of the first day after surgery and, over 7 days, 24 (43%) patients had vomited on one or more occasion. Three patients reported that they had vomited during the journey home. Vomiting was not correlated with pain or a past history of post-operative nausea and vomiting. However, there was a statistically significant correlation between nausea and pain. The high incidence of nausea and vomiting observed in this study appears to provide additional evidence of an oculo-emetic reflex. The timing of discharge and appropriate patient education are discussed.

An audit of post-operative nausea and vomiting (PONV) was undertaken in 935 female patients who used morphine patient-controlled analgesia (PCA) for pain relief after major gynaecological operations in a district general hospital. We investigated retrospectively five different antiemetic policies and a reference group without policy from January 1993 to July 1995. The department’s computerized audit system was used to analyse the observations. At the beginning of the audit, the incidence of nausea and vomiting was as high as 71.5%. But as a consequence of this audit, a departmental policy was adopted 3 years later, which had an incidence of PONV of only 51.7%. During this time the compliance with antiemetic protocols increased from 41% to 76%. There was significantly less PONV if an antiemetic protocol was followed (P=0.002). This emphasizes the importance of corporate involvement in the development, formulation and evaluation of departmental protocols if compliance is to be high. We conclude that audit as a corporate effort improves the acceptance of departmental protocols. This reduces PONV significantly irrespective of the type of antiemetic drug used.

A 43-year-old male received intravenous propofol, atracurium and gentamicin and experienced cardiovascular collapse with the features of an acute drug reaction. Prolonged cardiopulmonary resuscitation with fluids and large amounts of adrenaline and nor-adrenaline led to full recovery without neurological deficit. No biochemical abnormality was detected.

We report a case of non-ketotic hyperosmolar coma, which presented with blood sugar levels far exceeding any previously recorded in the literature. The patient developed acute renal failure, probably because of rhabdomyolysis, which was successfully managed with continuous veno-venous haemofiltration. He developed blurring of vision resulting from biochemical changes, which was managed conservatively. We discuss the mechanisms of causation of the renal failure and visual blurring.

Hereditary angio-oedema is an autosomal dominant condition resulting in a deficiency of C1 esterase inhibitor protein in serum. The condition is characterized by oedematous attacks in the skin, mucous membranes and gastrointestinal tract triggered by mental and physical stress. We present the rare case of a young girl with known hereditary angio-oedema and spina bifida occulta being admitted for an elective pilonidal sinus excision. This case presented different challenges for the anaesthetists and surgeons.

We report the case of a 33-year-old woman who developed a dense hemiplegia immediately after an uncomplicated general anaesthetic for diagnostic laparoscopy. She had a history of recurrent hemiplegic migraine with a strong family history. Her migraine was normally associated with visual disturbances and a unilateral headache followed by a left-sided weakness such that she was unable to walk. Symptoms would last up to 24 h. Her post-operative state was atypical of her normal migraine, in that she had no headache or visual disturbance and initially all four limbs were affected.