Local and systemic immune and haemostatic responses were studied in 10 patients, aged 57–78 years, undergoing elective hip arthroplasty. Cytokines, soluble cytokine receptors, interleukin-1 receptor antagonist, soluble adhesion molecules, antithrombin, fibrin, soluble and fibrin d-dimer were analysed in wound drainage blood and in blood taken from the systemic circulation for up to 24 h post-operatively. Wound drainage blood concentrations of cytokines, interleukin-1 receptor antagonist and soluble cytokine receptors were increased compared with those in the systemic circulation except for the soluble interleukin-6 receptor. In wound drainage blood, soluble tumour necrosis factor receptors (P<0.05), interleukin-1 receptor antagonist (P<0.05) and interleukin-6 (P<0.05–<0.01) increased during the study period. In blood from the systemic circulation interleukin-6 increased (P<0.05) while the soluble interleukin-6 receptor decreased (P<0.05) compared with pre-operative values. Concentrations of soluble adhesion molecules did not change. Wound drainage blood showed marked hypercoagulation. After hip arthroplasty pro-inflammatory cytokines and their inhibitors were mainly confined to the local trauma site. A predominance for inhibitors was noted.

A telephone audit was carried out on patients 24 hours after day case surgery. An initial audit shortly after the day case opened indicated pain scores and nausea that were considered unacceptable. Some 8.6% of patients called their family doctor (GP) to visit their home in the post-operative period. Pre-operative Piroxicam 20 mg was then initiated (in most patients) to reduce the pain scores, which it did. Only one patient in 111 (0.9%) called their GP out, but nausea scores remained unchanged. Methods to reduce this index are suggested.

We have studied the optimal diluent volume for post-operative analgesia and sedation produced by epidurally administered midazolam after upper abdominal surgery. Sixty patients were randomly allocated to four groups of 15 patients. When patients complained of pain after surgery, epidural midazolam 0.05 mg kg−1 in 3 mL saline (Group A), in 5 mL saline (Group B), in 10 mL saline (Group C) or in 15 mL saline (Group D) were injected as a bolus. The sedation was better and lasted longer in groups B and C than in the other two groups. Groups B and C also had significantly more extensive areas of analgesia than groups A and D from 30 min after the administration of midazolam. The interval to the second request for an analgesic was significantly shorter in Group D than in the other three groups. Memory retention of the pin-prick examination was reported by four patients in Group A. The present results indicate that 5–10 mL saline is the optimal volume for epidural injection when using midazolam 0.05 mg kg−1 for post-operative analgesia following upper abdominal surgery.

Forty-two children (aged 27–16 years) were randomly assigned to receive either sevoflurane (n=21) or halothane (n=21) in nitrous oxide/oxygen. After premedication with midazolam, anaesthesia was induced by facemask and the anaesthetic concentration was increased until loss of eyelash reflex (sevoflurane, 6%; halothane, 2.5%). Thereafter, 1–1.5 MAC of the inhalational agents were maintained until skin closure. Intra-operative analgesia was provided either by intermittent intravenous (i.v.) bolus doses of fentanyl (2–3 μg kg−1) or by a regional blockade. Induction was smooth and the time to loss of eyelash reflex was slightly shorter with sevoflurane than with halothane, the difference not quite reaching statistical significance (P=0.06). In both groups, heart rate remained stable and blood pressure decreased significantly during induction. Haemodynamic parameters remained stable during anaesthetic maintenance; no cardiac dysrhythmias were observed. Emergence time with sevoflurane was 12.9 min vs. 16.3 min with halothane, but this difference was not statistically significant. It is concluded that sevoflurane is as suitable for paediatric patients as halothane. The slightly faster emergence time offered by sevoflurane over halothane was of no clinical significance in the present study.

This study was undertaken to determine the minimum effective dose of granisetron, a selective 5-hydroxy-tryptamine type 3 receptor antagonist, for the prevention of post-operative nausea and vomiting (PONV) in female patients undergoing elective laparoscopic cholecystectomy. In randomized, placebo-controlled, double-blind study, 120 women were assigned to receive either placebo (saline) or granisetron at three different doses (20 μg kg−1, 40 μg kg−1 or 80 μg kg−1) intravenously immediately before the induction of anaesthesia. All patients received standardized aesthesia consisting of isoflurane and nitrous oxide in oxygen. The incidence of PONV during the first 24 hours after anaesthesia was 43, 40, 13 and 13% after administration of placebo and granisetron 20 μg kg−1, 40 μg kg−1 and 80 μg kg−1, respectively (P<0.05, overall Fisher's exact probability test). Adverse effects post-operatively were not different among the groups. In conclusion, granisetron 40 μg kg−1 is the minimum effective dose in the prevention of PONV after laparoscopic cholecystectomy.

The aim of the present study was to investigate the effect of intravenously (i.v.) administered fentanyl and clonidine on ventilation in 12 healthy male volunteers (age 30.8±4.9 years) who either received fentanyl alone (1.5≥μg kg−1) or fentanyl (1.5≥μg kg−1) in combination with clonidine (3≥μg kg−1). The effect on ventilation was measured with a CO2 rebreathing system. The respiratory depression caused by fentanyl disappeared 120 min after injection. The corresponding slopes were 7430±2075 mL kPa−1 prior to (t0) and 6263±1864 mL kPa−1 120 min post-application (base-line vs. t120; P=0.106). An impaired ventilatory response was observed during CO2 rebreathing at t120 after the injection of fentanyl and clonidine. Before drug administration, the slope of the response curves was 7700±2800 mL kPa−1, which was reduced to 5480±2135 mL kPa−1 (P<0.035) at t120. These data suggest a prolongation of a fentanyl-induced ventilatory depression when used in combination with clonidine.

The present study contrasted the pharmaco-economics and analgesic efficacy of intramuscular (i.m.) opioid treatment with a parenteral disposable patient-controlled analgesia (PCA) system in two groups of 20 female patients (ASA I–II, aged 35–69 years) scheduled for abdominal hysterectomy. The PCA group received a continuous infusion of 1.5 mg h−1 piritramide, a μ-opioid receptor agonist, with incremental doses of 1.5 mg (lock-out interval=15 min). The i.m. group received 0.3 mg kg−1 piritramide i.m. when requested by the patient with a minimum interval of 5 h. Pain intensity, sedation and the functional recovery of the patients were followed for 72 h post-operatively. The sum of pain intensity differences (SPID) was used as a measure of analgesic efficiency. Equipment and drug costs, and the demand on nursing time were recorded over 3 days post-operatively. The costs of PCA and i.m. therapies per patient were used to calculate the cost-benefit (cost of treatment vs. nursing time) and cost-effectiveness (cost of treatment vs. SPID) analyses. Both treatments initially provided comparable analgesia, but PCA was more efficient after 16 h and significantly reduced nursing time for pain treatment (PCA=61±4 min, i.m.=88±5 min; P<0.001). Functional recovery was not different for either treatment. Cost analysis indicated a better cost-benefit ratio for the i.m. treatment (0.35 vs. 1.1 for PCA treatment), but a similar cost-effectiveness for both treatments (PCA=1.9 Belgian Francs (BEF) unit−1 SPID; i.m.=1.7 BEF unit−1 SPID).

Eighty patients were recruited into a double-blind, randomized trial to find the optimal dose of droperidol for addition to the patient-controlled analgesia (PCA) morphine infusate for female patients undergoing gynaecological surgery. A standardized anaesthetic technique was employed. Post-operative analgesia was provided by PCA morphine. Patients were allocated at random into one of four treatment groups receiving with each PCA morphine bolus: (1) droperidol 0.05 mg; (2) droperidol 0.10 mg; (3) droperidol 0.15 mg; and (4) droperidol 0.20 mg, respectively. The incidence of post-operative nausea and vomiting (PONV), requests for rescue anti-emetic medication, and incidence of side effects were recorded. The number of symptom-free patients in each group increased as the droperidol dose increased, but although there was a significant inverse association between the total dose of droperidol received and the severity of PONV (P<0.05), there were no significant differences between individual groups. In each group, patients were significantly less sedated at 24 h compared with 12 h (P<0.01). However, after 24 h, patients in group 4 were significantly more sedated than patients in groups 1 and 2 (P<0.05). There were no significant differences between the groups in terms of the incidence of anxiety or other side effects attributable to droperidol. The present authors suggest that, although the results demonstrate few statistically significant differences between the four groups, a PCA bolus dose of droperidol of 0.10 mg mL−1 appears to provide the optimal balance between anti-emetic efficacy and an acceptable incidence of side effects.

In order to compare the neuromuscular effects following rocuronium 0.6 mg kg−1 and atracurium 0.5 mg kg−1 30 children aged from 18 to 67 months were studied under the same anaesthetic conditions. After induction of anaesthesia with etomidate and fentanyl, neuromuscular blockade was monitored by recording the electromyographic response of the adductor pollicis muscle to a supramaximal train-of-four (TOF) stimulation of the ulnar nerve at 2 Hz for 2 s at 20-s intervals. Intubation was performed when more than 90% muscle relaxation was achieved, thereafter anaesthesia was maintained with 70% nitrous oxide in oxygen and isoflurane 0.5% end-tidal. Mean onset of action was significantly faster following rocuronium (86±44.9 s) (mean±SD) compared with atracurium (126.3±61.0 s). Clinical duration with rocuronium was 22.8±5.31 min and thus significantly shorter than that of atracurium, which was 31.5±6.01 min. A statistically significant difference between rocuronium and atracurium also had been found for recovery of T1 to 50%, 75% and 90% as well as for the time taken to a TOF ratio of 70%. The recovery index for rocuronium and atracurium was not significantly different with 9.2±3.43 min and 10.9±2.65 min, respectively. Thus, rocuronium may be more advantageous than atracurium for short-lasting surgical procedures in young children.

Checking the anaesthetic machine before its daily use is essential. The aim of our study was to evaluate, through the use of an anonymous questionnaire, how the anaesthetists of our institution (physicians and nurses) report their daily checking. Sixty-three questions were used to ask the participants how frequently they checked the main components of the anaesthetic machine; the answers were evaluated with a score (0–3). The overall response rate was 78%, nurses' rate being lower than physicians' rate. Nurses obtained a higher global score, which raises the question of different adherence to guidelines by nurses and physicians. Moreover, questions in relation to gas supply were badly scored by all participants, which should alert us to reinforce theoretical and practical training in these items. Finally, although the methodology used in this survey could raise the question of the best way to evaluate the actual checkout procedure, self-reported assessment remains an alternative to more complex and expensive methods, such as an observer or a video evaluation.

A randomized crossover study was designed using the chronically instrumented pregnant sheep preparation to study the possible effects of epidural injection of adrenaline as a single compound on the circulation of mother and fetus. Three consecutive identical doses of adrenaline were administered epidurally with a 30 min interval between treatments. In a randomized crossover fashion two dosages (10 and 15 μg) were tested on different days. The day after the last epidural experiment the same doses of adrenaline were given intravenously (i.v.). Between the two i.v. doses a 30 min interval was allowed for values to return to baseline. Twenty-seven experiments were performed in eight ewes. Epidural administration of adrenaline did not affect maternal mean arterial pressure, maternal heart rate, uterine blood flow, fetal mean arterial pressure, fetal heat rate, or maternal and fetal blood gases and acid-base status. After i.v. administration of adrenaline the uterine blood flow decreased in a dose-dependent fashion, but the other haemodynamic variables were not affected. In conclusion, this study indicates that consecutive epidural injections of adrenaline have no significant effect on maternal and fetal haemodynamic responses, uterine blood flow, blood gases and acid–base status in the gravid ewe. However, an i.v. injection of 10 or 15 μg adrenaline decreases the uterine blood flow and could compromise the fetus.

Application of high-silica zeolites in a special adsorber anallows complete selective adsorption of the inhalation anaesthetic desflurane from the outlet port of the scavenging system of the anaesthesia machine. In comparison with charcoal filters, zeolites allow almost complete desorption at moderate temperatures followed by condensation of the desflurane to the liquid phase. The adsorption of scavenged desflurane by zeolites was measured in 13 patients. The duration of the anaesthesia was between 70 and 130 min. A minimal-flow regime (0.5 L min−1 fresh gas inflow) was used for maintenance in seven patients and a higher-flow regime (3 L min−1 fresh gas flow) was used for maintenance in six patients. In minimal-flow anaesthesia, 62% of the delivered desflurane was adsorbed by the zeolite while 86% of the delivered desflurane was adsorbed in higher-flow anaesthesia. Preliminary results show that about 85% of the adsorbed desflurane could be recovered as liquid with high purity via desorption.

The prediction of difficult intubation in obese patients was investigated by co-estimating the degree of visbility of oropharyngeal structures in conjunction with the respective body mass index. Data were collected prospectively in a series of 1833 consecutive adult patients. Body mass index (BMI) in kg m−2 was used as a measure of obesity (morbid: >40, moderate: 30–40, no obesity: <30). The oropharyngeal class findings were assessed using the original methodology as well as by a modification requiring the tongue to be pulled forward by the examiner. Difficult intubation was defined as inadequate exposure of the glottis by direct laryngoscopy. Both oropharyngeal class methodologies were of equal sensitivity, whereas the modified technique presented a significantly higher positive predictive value (50.0% vs. 37.2%, P<0.01). Statistical analysis revealed an increased risk of dificult laryngoscopy among obese patients compared with subjects with normal body mass index (20.2% vs. 7.6%, P<0.001). When obesity is estimated with respect to oropharyngeal class the positive predictive value is greately improved (66.7% vs. 20.2%, P<0.001). We conclude that obesity which is associated with a disproportionately large base of the tongue, is a predisposing factor for difficult laryngoscopy.

Rocuronium administration may cause tachycardia and an increase in cardiac index. Pancuronium, another steroidal non-depolarizing muscle relaxant, augments release of, and blocks re-uptake of catecholamines at adrenergic nerve endings. This study compared the haemodynamic effects of, and changes in catecholamine concentrations following administration of vecuronium (0.12 mg kg−1) or rocuronium (0.9 mg kg−1) to elderly patients. Thirty patients, 65 years or older, not receiving β-blockers, were studied. During thiopentone, fentanyl, nitrous oxide anaesthesia, either rocuronium (0.9 mg kg−1) or vecuronium (0.12 mg kg−1) was administered, according to random allocation. In all 30 patients, blood pressure and heart rate were measured before induction of anaesthesia, immediately and 1 min after induction, 1 and 2 min after muscle relaxant administration, and immediately, 1 and 2 min after tracheal intubation. In the latter 20 patients, samples for plasma catecholamine estimation were obtained prior to, and 1 min after muscle relaxant administration and 1 min after tracheal intubation. Blood pressure and heart rate were similar in the two groups throughout the study. Plasma noradrenaline concentrations were similar in the vecuronium and rocuronium groups prior to muscle relaxant administration (589(SD240) and 444(SD213) pg mL−1, respectively), 1 min after muscle relaxant administration (602(SD220) and 520(SD392) pg mL−1, respectively) and 1 min after tracheal intubation (597(SD351) and 440(SD181) pg mL, respectively). There was no significant change in either plasma noradrenaline or adrenaline concentrations in either group following muscle relaxant administration or tracheal intubation. The use of rocuronium (0.9 mg kg−1) in elderly patients does not result in a clinically significant change in heart rate, blood pressure or plasma catecholamine concentration.

This study was undertaken to determine whether epidural analgesia has any benefit for post-operative pain relief in patients undergoing laparoscopic cholecystectomy. Patients were randomly assigned to receive post-operative epidural analgesia with a morphine–bupivacaine combination (Group A, n=22) or placebo (saline) (Group B, n=22). The same standard general anaesthetic technique, which consists of nitrous oxide and isoflurane in oxygen was used. Analgesia was assessed using visual analogue pain scores (0–10 cm). The evaluation was carried out 24 and 48 h post-operatively. At 24 h after anaesthesia, pain scores in Group A (2.3±1.2) were lower than those in Group B (4.4±1.5) (P<0.05). However, at 48 h post-operatively, no difference in scores was observed between the two groups. In conclusion, epidural analgesia with a morphine–bupivacaine combination improves pain relief during the first 24 h following laparoscopic cholecystectomy.

Cardiac and major abdominal surgery are associated with granulocytosis in peripheral blood. The purpose of the present study was to describe the granulocyte and monocyte oxidative burst and the expression of adhesion molecules following cardiac surgery with cardiopulmonary bypass and abdominal surgery. The ability to respond with an oxidative burst was measured by means of flow cytometry using 123-dihydrorhodamine. The adhesion molecules CD11a/CD18, CD11c/CD18, CD44 were measured using monoclonal antibodies. Blood samples from eight patients undergoing open-heart surgery were taken before surgery, 1, 5, 10 and 20 min after aortic clamping, and then 1, 5, 10 and 20 min and 1, 2 and 3 h after declamping. Samples from eight patients undergoing abdominal surgery were taken before surgery, at the end of surgery, and 2 and 3 h post-operatively. A decrease in number of granulocytes and monocytes during cardiopulmonary bypass was observed. The percentage of CD11a-positive granulocytes increased from 30% preoperatively to 75% following cardiopulmonary bypass, while CD44-positive granulocytes increased from 5% to 13%. Despite the extent of the changes, these were not significant. The oxidative burst of the granulocytes and monocytes decreased after declamping to 15% and 27% of initial values in vitro. Several hours after surgery, there was no significant difference between the two groups. These results can be explained by a granulocyte and monocyte refractory response developing subsequent to an increased per-operative oxidative burst activity, and the induction of adhesion molecules on granulocytes associated with the cardiopulmonary bypass and surgery. In conclusion, open-heart surgery with cardiopulmonary bypass was associated with a rapid and pronounced activation of leukocytes which may play a role in reperfusion injury.

A 17-nation survey was undertaken with the aim of studying the availability of acute pain services (APS) and the use of newer analgesic techniques, such as epidural and patient-controlled analgesia (PCA). A questionnaire was mailed to selected anaesthesiologists in 105 European hospitals from 17 countries. Depending on the population, between five and ten representative hospitals from each country were selected by a country coordinator. A total of 101 (96.2%) completed questionnaires were returned. A majority of respondents were dissatisfied with pain management on surgical wards. Pain management was better in post-anaesthesia care units (PACUs); however, 27% of participating hospitals did not have PACUs. There were no organized APS in 64% of hospitals, although anaesthesiologists from chronic pain centres were available for consultation. In the hospitals that had APS, the responsible person for the APS was either: (1) a junior anaesthesiologist (senior anaesthesiologist available for consultation); or (2) a specially trained nurse (supervised by consultant anaesthesiologists). Many anaesthesiologists were unable to introduce techniques such as PCA on wards because of the high equipment costs. Although 40% of hospitals used a visual analogue scale (VAS) or other methods for assessment of pain intensity, routine pain assessment and documenting on a vital sign chart was rarely practised. There was a great variation in routines for opioid prescription and documentation procedures. Nursing regulations regarding injection of drugs into epidural and intrathecal catheters also varied considerably between countries. This survey of 105 hospitals from 17 European countries showed that over 50% of anaesthesiologists were dissatisfied with post-operative pain management on surgical wards. Only 34% of hospitals had an organized APS, and very few hospitals used quality assurance measures such as frequent pain assessment and documentation. There is a need to establish organized APS in most hospitals and also a need for clearer definition of the role of anaesthesiologists in such APS.

In this case report, the anaesthetic management for a removal of phaeochromocytoma undertaken immediately following Caesarean section is described. A 32-year-old female patient was given epidural anaesthesia for Caesarean section, and thereafter, general anaesthesia for a resection of phaeochromocytoma. During surgery, phentolamine, nitroglycerine and prostaglandin E1 were electively administered to decrease blood pressure and heart rate. A live infant was delivered and the supra-adrenal tumour was excised successfully. The patient's post-operative recovery was uneventful.