We describe the proximal cranial needle approach for brachial plexus blockade; clear surface markings and cranial direction of the needle lead to satisfactory results with a low incidence of complications.

A 4-month-old boy with Proteus syndrome underwent a successful operation for a left abdominal mass due to hydroureter and hydronephrosis with left ureterovesical stenosis. The operation lasted 4.5 h under general anaesthesia; there were no anaesthetic complications. There is only one previous report on anaesthesia in a patient with Proteus syndrome.

A critical incident is described where the expiratory (scavenging) port of an obsolete version of a Bain-type breathing system valve assembly was inadvertently connected to the common gas outlet of an anaesthetic machine. This resulted in the patient being deprived of a supply of fresh gas. This misconnection was made possible by adding a plastic connector to the valve scavenging port and subsequent wrongful misconnection. The patient fortunately suffered no harm. The case highlights the danger of equipment that has been subjected to unauthorized interference.

We evaluated the ability of inexperienced personnel in using a prototype illuminated flexible catheter to assist tracheal intubation through the intubating laryngeal mask in anaesthetised, paralysed patients. The device consists of a completely flexible thin plastic catheter, a bulb attached to its distal end and a 15-mm concentric adapter at its proximal end. The illuminated catheter is placed into a straight silicone tracheal tube in such a way that the bulb is placed at the distal end of the tracheal tube. Six nurses inexperienced in tracheal intubation followed a 2-hr training program by using the device through the intubating laryngeal mask in a mannequin and then intubated 10 patients each, with instruction from an anaesthetist. All patients (n = 60) were ASA 1–2, scheduled to undergo general anaesthesia for elective surgery. After fentanyl/propofol induction the intubating laryngeal mask was inserted. When an adequate airway was established, patients received atracurium and the endotracheal tube preloaded with the device was inserted through the intubating laryngeal mask and by observing the glow in the neck was advanced into the trachea. The final outcome and the duration of the procedure were recorded. The intubating laryngeal mask was inserted successfully in all patients. The success rate of intubation was 57/60 (95%); 38 patients at first attempt and 19 after two or three attempts. The mean (±SD) duration of the procedure in the first five patients in the series of each nurse was 74±40 s while in the last five patients it was diminished to 52±23 s (P= 0.01). We conclude that the described methodology has the potential for more widespread use of tracheal intubation through the intubating laryngeal mask even by inexperienced personnel.

Patients with bilateral corneal blindness in whom corneal transplantation has either been unsuccessful or inappropriate may be considered for osteo–odontokeratoprosthesis surgery. During a two–stage procedure the surface of the cornea is removed and covered with a graft of buccal mucosa. An optical cylinder, supported by an osteo–odonto lamina planed from a tooth is then inserted into the mucosa to act as a lens. The anaesthetic implications of this operation include care of patients from a wide age range, often with underlying medical problems undergoing two operations of prolonged duration. The eye can be ‘open’ during both stages of the operation and anaesthetic techniques directed towards prevention of rises in vitreal pressure are essential. This article outlines the surgical process of osteo-odonto-keratoprosthesis surgery with reference to our anaesthetic experiences from nine cases.

A prospective observational study of 101 women having breast surgery under general anaesthesia was performed to assess the extent of postoperative nausea and vomiting in this group of women. The overall rate of postoperative nausea and vomiting was high, 56% and 41%, respectively, and was significantly associated with length of surgical procedure and morphine use. Techniques to reduce morphine requirement should be evaluated to try and reduce this cause ofmorbidity.

Treatment of ingrowing toenail is commonly performed under local anaesthesia with a digital ring block. Ring block can be associated with significant pain, caused by needle insertion and deposition of the local anaesthetic agent. EMLA, a topical anaesthetic cream, is widely used to alleviate the pain of venepuncture. The aim of this study was to investigate whether the discomfort of digital block could be reduced by prior application of EMLA. Fifty–five patients who were scheduled for ingrowing toenail under local anaesthesia were randomized into two groups. In Group 1 (n = 30), EMLA was applied around the base of the affected hallux for at least 1 h before ring block. In Group 2 (n = 25), a placebo cream was used. In this double-blind study, patients assessed the pain caused by a standardized ring block using 100-mm visual analogue pain score. The mean visual analogue pain score in Group 1 was 28.1 and 50.1 in Group 2 (P<0.0001). We conclude that EMLA significantly reduces the pain associated with digital ring block.

Sudden accidental loss of the airway during surgery is potentially hazardous especially when the patient is lying in any position which prevents easy intubation of the trachea. We describe two patients lying in the lateral position who required urgent airway management and endotracheal intubation. In both cases endotracheal intubation was achieved successfully using a light–guided technique – with a prototype illuminated flexible catheter – through an intubating laryngeal mask airway.

The effects of intravenous and epidural clonidine, 4 μg kg−1, combined with epidural morphine, 40 μg kg−1, on the neuro-endocrine and immune stress responses to thoracic surgery are reported. A control group received only epidural morphine. Anaesthesia was induced and maintained with propofol. Catecholamines, vasopressin, cortisol, β-endorphin concentrations and leucocyte counts were measured before drug administration, immediately after intubation of the trachea, after thoracotomy and at the end of surgery. Catecholamines did not change in any of the groups. The other stress hormones increased during surgery, the pattern being similar in the three groups. Total leucocyte and neutrophil counts were increased in all groups at the end of surgery, but the increase was least in the epidural clonidine group. The number of lymphocytes was reduced at the end of surgery in the epidural and intravenous group, compared with the control group in which the number of lymphocytes did not change. The effects are more pronounced with epidural than with intravenous administration. We conclude that clonidine can modulate the immune stress response to thoracic surgery.

We describe a patient with aortic dissection extending into the right coronary artery who was successfully resuscitated and operated upon after a cardiac arrest during transfer to the operating room. The use of transoesophageal echocardiography was particularly helpful for rapid diagnosis of aortic type A dissection and urgent surgical treatment.

In this prospective pilot study, nine patients suffering from complex regional pain syndrome of the arm were treated with morphine 0.16mg h−1 (3.84mg day−1) applied continuously through an axillary brachial plexus catheter. In all of them an oral analgesic medication including the less potent opioid tramadol had not provided sufficient pain relief. During regional treatment, patients were kept in hospital and physiotherapy was carried out frequently in order to improve strength and function of the affected arm. Pain at rest and during movement as well as grip strength were assessed at first visit, during morphine infusion and at a long–term follow–up visit. All assessments improved significantly during plexus analgesia. There were no major opioid related side–effects. The results from this pilot study indicate that continuous axillary brachial plexus analgesia with low dose morphine might be beneficial in patients suffering from complex regional pain syndrome of the arm.

The management of surgical embolization of a post-traumatic carotid-cavernous fistula is reported in this study. The procedure was successfully performed with the aid of a fibreoptic intravascular catheter, which was monitoring continuously the changes of the jugular venous oxygen saturation. Jugular venous oxygen saturation monitoring effectively confirmed the success of embolization without the need for intraoperative angiography, by manifesting an abrupt return of oxygen saturation from arterial to normal venous values immediately after embolization.

We investigated the effect of a small dose of midazolam, ketamine, droperidol or lidocaine on the propofol dose required for hypnosis during induction of general anaesthesia. These drugs were randomly administered to 100 patients about to undergo scheduled surgery. Propofol was then infused at a rate of 250 μg kg−1 min−1 and the hypnotic dose to produce hypnosis was evaluated. Midazolam (20 μg kg−1) and droperidol (20 μg kg−1) significantly reduced the mean hypnotic dose of propofol (mean) S.D.) compared with the placebo (43.7 ± 17.8 mg, 61.9 ± 10.6 mg and 72.5 ± 27.7 mg after pretreatment with midazolam, droperidol and placebo, respectively), whereas ketamine (0.1 mg kg−1) and lidocaine (1 mg kg−1) did not significantly affect the hypnotic dose of propofol (63.1 ± 25.6 mg and 65.1 ± 24.8 mg, respectively). Only midazolam when compared with saline administration, (176 ± 66s and 298 ± 126s, respectively), shortened the time to achieve hypnosis. The changes in blood pressure (non-invasive) and heart rate were not significantly different in all groups during the induction of anaesthesia and oro-tracheal intubation. These results raise the possibility that new combinations of central nervous system drugs, such as droperidol and propofol, have a potential to reduce the dose of intravenous anaesthetics, including propofol, that produce hypnosis without significant adverse effects.