Background and objective: The aim was to compare the effects of two different priming doses and priming intervals with the standard intubating dose of rocuronium on the onset time and intubation conditions.

Methods: After induction of anaesthesia, 75 patients were randomly assigned to one of five groups. Patients in Group 1 received a priming dose of rocuronium 0.06 mg kg−1 followed 2 min later by rocuronium 0.54 mg kg−1, Group 2 received a priming dose of 0.10 mg kg−1 followed 2 min later by a rocuronium injection of 0.50 mg kg−1. Group 3 was given a priming dose of 0.06 mg kg−1 followed 3 min later by administration 0.54 mg kg−1, where Group 4 received a priming dose of 0.10 mg kg−1 followed 3 min later by injection of 0.50 mg kg−1. Group 5 received a placebo injection followed 3 min later by rocuronium 0.60 mg kg−1.

Results: Priming with a 3 min priming interval shortened the onset time of rocuronium irrespective of the dosage of (P < 0.001). Clinical duration of action was significantly longer after priming in Group 4 than in Group 5. Clinically acceptable intubation conditions were obtained in all patients.

Conclusions: Priming with a 3 min priming interval was effective when rapid tracheal intubation with rocuronium was necessary. However, priming with rocuronium should be used carefully with special attention given to the possibility of hypoxia and aspiration of gastric contents in awake patients.

Background and objective: To compare the application of the cuffed oropharyngeal airway and the laryngeal mask airway on anaesthetized adult patients undergoing minor outpatient surgery.

Methods: One hundred patients received intravenous fentanyl, propofol and N2O for the induction and maintenance of anaesthesia. The patients were randomly divided into two groups: a cuffed oropharyngeal airway group (n = 50) and a laryngeal mask airway group (n = 50). After insertion of the device, fibreoptic laryngoscopy was attempted and the degree of success scored. We then compared the first application success rate of both procedures while judging airway intervention requirement, fibreoptic scores, adverse airway events and haemodynamic tolerance.

Results: Both devices had an almost similar first-time placement rate (cuffed oropharyngeal airway 84% versus laryngeal mask airway 96%). The cuffed oropharyngeal airway required a higher number of airway interventions (P < 0.001). The laryngeal mask airway had a significantly better fibreoptic view compared with the cuffed oropharyngeal airway (P < 0.001). However, the number of adverse airway events was lower in the cuffed oropharyngeal airway group; there were no significant differences in adverse events and haemodynamic variables between the said two groups.

Conclusions: The results suggest that the cuffed oropharyngeal airway was an effective alternative airway in spontaneously breathing patients during short procedures.

Background and objective: The effects of remifentanil, alfentanil and fentanyl were compared on cardiovascular responses to laryngoscopy and endotracheal intubation in morbidly obese patients.

Methods: Eighty morbidly obese ASA I–II patients were included in the study. Patients were randomly divided into four groups to receive either 1 μg kg−1 fentanyl (Group F), 10 μg kg−1 alfentanil (A), 1 μg kg−1 followed by an infusion of 0.5 µg kg min−1 remifentanil (R) or saline (P). The patients corrected weight was used to calculate the drug doses. Body mass indices (range) were: 54.3 ± 7.37 (49–78.4), 55.67 ± 7.44 (48.5–78.4), 53.17 ± 5.36 (48.1–63.2), and 56.3 ± 6.09 (46.6–67.7) kg m−2, in Groups F, R, A and P respectively. Systolic, diastolic and mean arterial pressures and heart rate were measured non-invasively at three time points, which were 2 min before induction, 2 min after induction and 2 min after endotracheal intubation.

Results: After induction of anaesthesia, arterial pressures decreased significantly in all groups, but the decrease was more pronounced in Groups A and R. After induction, heart rate decreased significantly in all groups except in Group P. After intubation, haemodynamic responses were similar in the remifentanil, fentanyl and alfentanil groups and were within normal limits. In Group P, arterial pressures and heart rates were significantly higher.

Conclusions: Alfentanil, fentanyl and remifentanil in the doses described had similar effects in controlling the haemodynamic response to tracheal intubation in ASA I–II morbidly obese patients.

Background and objective: Although combined spinal and epidural anaesthesia is efficient and easy to perform, the technique can be a double-edged sword having the potential risk that an increased flux of drugs across the meninges through the hole made in it may lead to severe adverse effects. The aim was to compare the incidence of adverse events when an epidural injection of morphine was given after combined spinal and epidural anaesthesia or after epidural anaesthesia.

Methods: Fifteen patients had an epidural catheter inserted at the L2–3 interspace, and then a spinal block administered via the L3–4 interspace. Another 15 patients only had an epidural catheter inserted. After the onset of spinal or epidural anaesthesia had been confirmed, morphine 2 mg was injected into the epidural space, and a continuous epidural infusion of morphine was started. At the end of the operation and at 4, 8 and 12 h after the administration of epidural morphine and on the next day, the following variables were examined: blood pressure, heart rate, respiratory rate, arterial blood-gas analysis, visual analogue scale pain scores, nausea/ vomiting scores, and pruritus scores.

Results: In the study population, the epidural injection of morphine was not associated with a significantly higher incidence of adverse events when given after spinal anaesthesia than after epidural anaesthesia.

Conclusions: The adverse effects associated with epidural morphine given after spinal anaesthesia did not increase significantly when a 27-G Whitacre needle was used. Thus, the morphine flux through the meningeal hole into the cerebrospinal fluid was trivial.

Background and objective: The aim was to examine the course of intraocular pressure after relaxation with different doses of cisatracurium.

Methods: The investigation was carried out as a prospective, randomized double-blind study in a crossover design in 30 postoperative patients with stable haemodynamic and respiratory function (ASA I and II). To exclude any disrupting factors, patients remained intubated and continuously sedated. Twenty patients received an intubation dose (2 × ED95) of cisatracurium (0.1 mg kg−1) compared with atracurium (0.5 mg kg−1). In a second series, 10 patients were given an effective dose, ED95 (0.05 mg kg−1), and a repeat dose (0.02 mg kg−1) of cisatracurium. The intraocular pressure was determined before (T0) as well as 1 (T1), 5 (T5), 10 (T10), 15 (T15), 20 (T20) and 45 (T45) min after bolus administration.

Results: Intraocular pressure decreased after an intubation dose of either cisatracurium or atracurium, and reached a minimum after 10 min (6.7 ± 2.2 and 7.9 ± 2.1 mmHg, respectively). There was no significant difference between either muscle relaxant (P = 0.27). When lower doses of cisatracurium (0.05 and 0.02 mg kg−1) were applied, the intraocular pressure also decreased, albeit to a lesser extent and with a delayed onset (8.4 ± 1.9 mmHg after 10 min, 9.9 ± 3.4 mmHg after 15 min). There was no significant difference between dosages (P = 0.44).

Conclusions: Cisatracurium is a useful drug in patients when a decrease of intraocular pressure is wanted and where muscle relaxation is necessary and acceptable.

Background and objective: This study was performed to identify risk factors for complications and in-hospital mortality associated with pneumonectomy.

Methods: The influence of fluid balance during anaesthesia was evaluated, taking into account the patient's age, gender and body mass index, smoking habits, history of pulmonary or cardiac disorders, the site of pneumonectomy and duration of anaesthesia. One-hundred-and-seven patients undergoing elective pneumonectomy were included in the study.

Results: A total of 31 patients (29%) suffered from one or more postoperative complications, seven (22.4%) of these had severe dysrhythmias, six (19.6%) had pulmonary complications and three (9.3%) had cardiovascular complications. The overall mortality rate was 10.3%.

Conclusions: Based on logistic regression analysis, our data indicate the following risk factors for postoperative complications: positive fluid balance exceeding 4000 mL during anaesthesia (pulmonary complications and mortality), body mass index < 17 or > 25 kg m−2 (severe dysrhythmias), or history of chronic heart disease (pulmonary complications). Thirteen patients (12.4%) suffered from a fluid balance 4000 ml during anaesthesia. Regression analysis indicated that fluid balance exceeding 4000 mL was associated with a higher risk of postoperative complications than blood loss exceeding 1000 mL and to be the strongest risk factor for postoperative pulmonary complications and in-hospital mortality. Further trials estimating the effect of restrictive fluid regimens and the use of vasopressors for blood pressure control during anaesthesia must be carried out.

Background and objective: Although the MAC>tetanus(minimum alveolar concentration that prevents movetetanus ment in response to electrical tetanus stimulation in 50% of patients) of isoflurane decreases during anaesthesia and surgery, it is not known whether this occurs to the same extent with other inhalational anaesthetics. We determined the MACtetanus of sevoflurane before and after surgery.

Methods: Eleven patients who underwent arthroscopy of the shoulder underwent inhalational induction of anaesthesia with sevoflurane and tracheal intubation by succinylcholine. MACtetanus was determined in each patient by testing the response to a 10 s, 50 Hz, 80 mA transcutaneous tetanic electrical stimulus to the ulnar nerve at varying concentrations of sevoflurane. The end-tidal concentration of sevoflurane was kept constant for 15 min before each stimulus and the concentration of sevoflurane varied in increments of 0.1% until a sequence of three alternate responses (move, not move, move) or (not move, move, not move) was obtained. After arthroscopy of the shoulder, individual MAC were measured as described above.

Results: The mean MACtetanus decreased from 2.22 ± 0.29% before arthroscopy to 1.82 ± 0.26% after arthroscopy (P < 0.01).

Conclusions: It is concluded that the MACtetanus of sevoflurane decreases during anaesthesia and surgery.

Background and objective: To evaluate the efficacy and optimal dose of prophylactic intravenous ephedrine for the prevention of maternal hypotension associated with spinal anaesthesia for Caesarean section.

Methods: After patients had received an intravenous preload of 0.5 L of lactated Ringer's solution, spinal anaesthesia was administered in the sitting position with hyperbaric bupivacaine 2.5 mL 0.5% combined with 25 μg fentanyl. A total of 68 patients were randomized to receive a simultaneous 2 mL bolus intravenously of either 0.9% saline (Group C, n = 20), ephedrine 6 mg (Group E-6, n = 24), or ephedrine 12 mg (Group E-12, n = 22). Further rescue boluses of ephedrine 6 mg were given if systolic arterial pressure fell to below 90 mmHg, greater than 30% below baseline, or if symptoms suggestive of hypotension were reported.

Results: There was a significantly higher incidence of hypotension in Group C (60% patients) compared to Group E-12 (27%), but not in Group E-6 (50%). The 95% Confidence Interval for the difference in proportions between Groups C and E-12 was 6-60%, P < 0.05. Fewer rescue boluses of ephedrine were required in Group E-12 compared with Group C (1.8 ± 1.2 vs. 3.3 ± 2.1, P < 0.05). There were no significant differences in the incidence of maternal nausea or vomiting, or of neonatal acidaemia between groups.

Conclusion: A prophylactic bolus of ephedrine 12 mg intravenously given at the time of intrathecal block, plus rescue boluses, leads to a lower incidence of hypotension following spinal anaesthesia for elective Caesarean section compared to intravenous rescue boluses alone.

Background and objective: The addition of alfentanil or atracurium to lidocaine solution for intravenous regional anaesthesia of the arm may have advantages with respect to improved muscle relaxation and better analgesia. The study investigates these possibilities.

Methods: We investigated 33 patients. Plain lidocaine solution was administered to Group 1 (n = 11). Alfentanil (0.5 mg) and atracurium (3 mg) were added to the lidocaine solution in Groups 2 (n = 11) and 3 (n = 11), respectively. The onset of sensory and motor block, intra- and postoperative pain scores, and the duration of postoperative analgesia were evaluated.

Results: There was a significant difference in the speed of the onset of sensory block in the hand, but not at the tourniquet site. The onset of the motor block, intra- and postoperative pain scores, and the duration of postoperative analgesia were similar in all groups.

Conclusions: No clinical benefits of adding alfentanil or atracurium to lidocaine solution for intravenous regional anaesthesia of the arm could be shown.

Background and objective: To compare the conditions for insertion of the laryngeal mask airway using sevoflurane or propofol plus fentanyl. We evaluated the haemodynamic changes and cost of induction of anaesthesia in both groups.

Methods: Sixty patients were equally and randomly divided into two groups. Both groups received fentanyl 1 μg kg−1. Patients in the sevoflurane group were induced with 8% sevoflurane and those in the propofol group with propofol 2.5 mg kg−1. Conditions for insertion were graded on a three-point scale using six variables. Overall, conditions were assessed as excellent, satisfactory or poor based on the total score in each group. Systolic and diastolic arterial pressure and heart rate were recorded for 6 min after mask insertion. The financial cost of induction in both groups was calculated.

Results: The mean (±SD) time taken from induction to successful laryngeal mask insertion was significantly shorter with propofol (68.70 ± 22.60 s) compared with sevoflurane (149.83 ± 55.25 s). Excellent or satisfactory conditions were observed in 30 (100%) patients in the propofol group and in 29 (96.66%) in the sevoflurane group. Systolic and diastolic arterial pressures were significantly lower in the propofol group. The cost of sevoflurane used was €3.95 ± 1.48 (Rs 216.23 ± 64.66) (P < 0.05) compared with that of propofol, which was €3.23 ± 0.65 (Rs 141.00 ± 28.20).

Conclusions: Although there was a faster induction with propofol-fentanyl, conditions for insertion of the laryngeal mask airway were similar in both groups. Haemodynamic stability was better with sevoflurane-fentanyl. The propofol-fentanyl combination was more cost-effective.

Background and objective: To determine whether prior exposure of non-steroidal anti-inflammatory drugs increases perioperative blood loss associated with major orthopaedic surgery.

Methods: Fifty patients scheduled for total hip replacement were allocated to two groups (double blind, randomized manner). All patients were pretreated for 2 weeks before surgery: Group 1 with placebo drug, Group 2 with ibuprofen. All patients were injected intrathecally with bupivacaine 20 mg plus morphine 0.1 mg, in a total volume of 4 mL, to provide surgical anaesthesia.

Results: The presence of severe adverse effects caused eight patients in the ibuprofen group and six in the placebo group to terminate their participation in the trial. The perioperative blood loss increased by 45% in the ibuprofen group compared with placebo. The total (±SD) blood loss in the ibuprofen group was 1161 (±472) mL versus 796 (±337) mL in the placebo group.

Conclusions: Pretreatment with ibuprofen before elective total hip surgery increases the perioperative blood loss significantly. Early discontinuation of non-selective non-steroidal anti-inflammatory drugs is advised.

Background and objective: Cardiovascular and mental stress in dental patients with phobias about dentistry may be reduced by propofol sedation. We tested the hypothesis that even low doses of propofol may have effects on body temperatures in male volunteers.

Methods: Six healthy male volunteers were given propofol over 28 min with the following infusion rates: 8 mg kg−1 h−1 for the first 3 min, 4 mg kg−1 h−1 for the next 10 min, and 2 mg kg−1 h−1 for the final 15 min. Body temperatures were measured at five locations: tympanic membrane, forehead, forearm, dorsum of the hand and fingertip. Thermoregulatory vasoconstriction was evaluated using the forearm minus fingertip temperature gradient.

Results: Tympanic membrane and forehead temperatures began to decrease at 10 and 20 min, respectively, after the start of the propofol infusion, and reached a minimum at 30 min (tympanic −0.5 ± 0.2°C) and 40 min (forehead −0.6 ± 0.2°C), respectively. Peripheral skin temperatures showed an increase between 10 and 30 min in the forearm and fingertip and between 20 and 30 min in the dorsum of the hand. After 30 min, a decrease in peripheral skin temperatures was observed. The forearm minus fingertip temperature gradient changed from negative to positive after 40 min, and increased continuously thereafter (baseline −0.3 ± 0.4°C, 90 min: 6.5 ± 1.6°C).

Conclusions: A low dose of propofol impairs tonic thermoregulatory vasoconstriction and induces heat redistribution from the core to the periphery.

Background and objective: Monitoring of neuromuscular blockade still often relies on clinical judgement. Moreover, there are substantial national differences in the use of agents to 'reverse' their effects. We investigated the recovery characteristics and incidence of postoperative residual curarization after cisatracurium and rocuronium infusions for long duration interventions without systematic antagonism.

Methods: In 30 patients undergoing major surgery, we measured infusion dose requirements for rocuronium and cisatracurium during propofol anaesthesia. Infusions were discontinued at the beginning of surgical closure; spontaneous recovery of neuromuscular function was awaited in both groups. Neostigmine (50 μg kg−1) was administered only when a patient started to wake without a train-of-four ratio (TOF) of 0.9.

Results: In the cisatracurium and rocuronium groups, four (27%) and one (7%) patients, respectively, had a TOF ratio ≥0.9 at the end of surgery. The TOF ratio in each group at that time was 51 ± 32% for cisatracurium and 47 ± 31% for rocuronium (P = 0.78). Six patients (40%) in the cisatracurium group and seven (47%) in the rocuronium group required neostigmine. The TOF ratio at the time of reversal was 63 ± 7% for cisatracurium and 40 ± 19% for rocuronium (P = 0.01). The time interval between the end of surgery and a TOF ratio of 0.9 was 10 ± 9 min for cisatracurium and 18 ± 13 min for rocuronium (P = n.s.).

Conclusions: Patients receiving a cisatracurium or rocuronium infusion have a high incidence of postoperative residual curarization when the block is not antagonized. When ‘reversal’ is not attempted, cisatracurium seems to be safer than rocuronium.

Background and objective: The intravenous anaesthetic propofol may become contaminated once the ampoules have been opened. The effect of lidocaine and cooling was tested on the bacterial contamination of propofol.

Methods: The study was performed in two parts. In Part 1, 1920 aliquots of propofol alone, and of a propofol-lidocaine mixture, were drawn into sterile syringes and stored at room temperature (24–26°C) or in the refrigerator (12–14°C). In Part 2, 1200 aliquots from opened ampoules of propofol alone, or as a propofol-lidocaine mixture, were stored at room temperature or in the refrigerator. Samples were aerobically cultured at 0, 1, 2, 4, 8, and 12 h.

Results: In Part 1, diphtheroid bacillus was isolated from one aliquot (0.06%). In Part 2, there was bacterial growth in both groups; the number of contaminated ampoules increased with time and it was 20–26% at 12 h. Diphtheroid bacilli and coagulase-negative staphylococci were the most frequent micro-organisms.

Conclusions: When propofol is stored in opened ampoules, the bacterial contamination rate is high. Adding lidocaine, or storing opened ampoules at 12–14°C, does not affect the contamination rate, except during the first few hours. It is advisable to draw propofol aseptically into a syringe in an amount that can be used during one procedure.