The present study describes the management of a myasthenic patient undergoing transsternal thymectomy for whom thoracic epidural anaesthesia using 15 mL of bupivacaine 0.5% combined with isoflurane 0.4% and nitrous oxide in oxygen 50% provided good intra-operative relaxation followed by an uneventful recovery and eliminated the need for other post-operative analgesics.

A healthy 22-year-old man received an initial injection of 12 mL of lignocaine/bupivacaine solutions (2 mL test, then 10 mL) into an epidural catheter. This produced a satisfactory regional blockade that seemed to be epidural but, when a supplementary 6 mL injection was given 1 h later, the patient developed impaired motor function as far as the upper cranial nerves, with loss of pinprick sensation to the shoulder. The emergence of fluid dribbling freely from the catheter prompted measurement of the pressure, which was 36 mmHg. The fluid was proved not to be cerebrospinal fluid (CSF) by the absence of glucose (on dextrostix), by the appearance of turbidity with added thiopentone, and later by microscopy. Slow aspiration of 7 mL of the presumed injectate reduced the pressure in the catheter to 8 mmHg, which promptly reversed the additional excessive blockade, allowing surgery to proceed uneventfully. The retrieval of injectate argues strongly that the catheter tip had found its way subdurally, and the promptness of the reversal with aspiration argues for a mechanical rather than a pharmacological cause for the extensive neurological dysfunction after the second injection. Pressure measurement and aspiration may be helpful in other similar cases.

The sensitivity of train-of-four (TOF) or double burst stimulation3,3 (BBS3,3) was examined to detect fade by visual inspection, at varying stimulating currents, using the thumb of the investigated arm maintained abducted by the use of a rubber band. One-hundred adult patients were allocated randomly to (1) train-of-four-rubber band (TOF-RB), (2) train-of-four-control (TOF-control), (3) double burst stimulation-rubber band (DBS-RB), or (4) double burst stimulation-control (DBS-control) group. Each group contained 25 patients. The thumb of the investigated arm was kept abducted using a rubber band in the TOF-RB band and DBS-RB group and was free in the TOF-control and DBS-control. TOF stimuli were delivered in the TOF-RB and TOF-control groups, and DBS3,3 in the TOF-RB and TOF-control at 50, 30 and 20 mA. The probability of visual detection of TOF fade was the same in the TOF-RB and TOF-control groups. In contrast, when measured TOF ratio was 0.51–0.80, at the stimulating current of 50 or 30 mA, the likelihood of visual detection of fade in the DBS-RB group was significantly higher than in the DBS-control group (P < 0.05). With a TOF ratio of 0.61–0.70, in the DBS-RB group the probability of visual detection of fade at 50 or 30 mA was significantly higher than at 20mA (P < 0.05). This study suggests that when using a rubber band, fade in response to the DBS3,3 is detected by visual inspection more readily at a stimulating current of 50 or 30mA than without the rubber band.

Extracorporeal shock wave lithotripsy using a spark gap generator is contraindicated in patients with complete atrioventricular heart block. A case of a patient with such a heart block, who successfully underwent renal lithotripsy, without cardiac pacemaker, is reported.

Factors affecting flow through blood administration sets in vitro were assessed under gravity-fed and pressurized conditions including an assessment of the influence of the intravenous (i.v.) cannula and Luer lock fitting. The fastest gravity-fed flow of 4.775 mL s−1 was obtained through the largest internal diameter (ID = 4.8mm) blood administration set. Flow through blood administration sets with ID = 3mm was 50% of this. Flow increased over base-line through all the administration sets when the i.v. cannula was removed (range 18–50%) and increased further over base-line when the Luer lock fitting was removed from the distal end (range 26–129%), indicating that these are rate-limiting steps in the system. The Y-type trauma set with the largest diameter tubing facilitated the fastest flow, although flow through all the Y-type trauma sets produced lower flow rates than the corresponding blood administration sets, which may reflect their relative increased length. The ideal blood administration set should have an internal diameter at least 4mm and be less than 170 cm in length.

Chondronecrosis of the cricoid cartilage is a rare complication of intubation. The records of two children were reviewed. An 8-month-old girl with myelomonocytic leukaemia developed chondronecrosis 10 days after a 2-day period of ventilation. A 4-year-old girl comatose after poisoning by the histamine antagonist, alimemazine, developed chondronecrosis after a 2-day period of intubation. The complication was suspected when extubation led to dyspnoea owing to laryngeal stridor and was confirmed by direct laryngoscopy. We review the development of the condition, the causative factors, treatment and prevention.

We report the occurrence of oesophageal perforation and dilatation during percutaneous tracheostomy. The Combitube was used for airway maintenance during this procedure. This case highlights the limitations of the Combitube when used in this situation.

Two patients presented with very different signs of central anticholinergic syndrome following general anaesthesia for which they had received premedication with hyoscine. Both responded dramatically to 1 mg of intravenous (i.v.) physostigmine, which produced a rapid return to a normal level of consciousness. The aetiology of central anticholinergic syndrome is multi-factorial, but the diagnosis should be considered in all patients who demonstrate abnormal post-anaesthetic awakening. It is recommended that 1 mg of intravenous physostigmine is a safe and effective treatment for central anticholinergic syndrome, and that a supply of this important drug must be kept readily available in the recovery area of the operating theatre department.

Two cases of atypical transurethral resection (TUR) syndrome occurring during the post-operative course are reported. Atypical clinical events such as confusion, drowsiness and sudden hypotension could not be explained by the amount of glycine fluid absorption, because in both cases this was less than 1000 mL. However, high serum concentrations of glycine were noted without marked hyponatraemia and with normal measured osmolalities. We suggest that the absorption of glycine is related to its high lipid solubility rather than to its direct passage through an evident prostatic effraction or periprostatic extravasation.