To determine whether intraoperative systemic dexmedetomidine improves postoperative pain and interacts with epidural neostigmine to produce analgesic effects.

Sixty patients undergoing gynaecological surgery were randomly divided into four groups to receive epidural neostigmine and/or systemic dexmedetomidine: control (Group C), epidural neostigmine (Group N), systemic dexmedetomidine (Group D) and co-administered neostigmine and dexmedetomidine (Group ND). Epidural neostigmine (0.3 mg) was administered with 10 mL of 0.75% ropivacaine before the induction of general anaesthesia. Systemic dexmedetomidine (loading dose of 1 μg kg−1 over 10 min followed by 0.4 μg kg−1 h−1) was infused after the induction of general anaesthesia and continued until the end of surgery. The pain status of patients was assessed using the visual analogue scale at 2, 4, 6, 24 and 72 h postoperatively.

Intraoperative systemic dexmedetomidine alone did not reduce postoperative pain scores. However, co-administered neostigmine and dexmedetomidine significantly decreased scores at 24 and 72 h (Group C: 3.0 [1.0–5.8] and 2.0 [0.3–3.0]; Group N: 1.5 [0.3–3.4] and 0 [0–1.3]; Group D: 3.5 [0–5.0] and 0 [0–1.4]; and Group ND: 0 [0–1.0]* and 0 [0–0]†; median [interquartile range] *P = 0.0031, †P = 0.0045 compared with Group C).

The intraoperative systemic infusion of dexmedetomidine alone at doses causing sedation does not result in postoperative analgesic effects. However, the co-administration of systemic dexmedetomidine and epidural neostigmine at higher doses may be a useful method to improve postoperative pain although side-effects have to be evaluated.

To compare induction, pre- and post-discharge recovery characteristics and patient preferences between four anaesthetic regimens in adult day-surgery.

Randomized controlled trial. In all, 1158 adults assigned to: propofol induction and maintenance, propofol induction with isoflurane/N2O, or sevoflurane/N2O maintenance, or sevoflurane/N2O alone. We prospectively recorded induction and pre-discharge recovery characteristics, collected 7-day post-discharge recovery characteristics using patient diaries and patient preferences by telephone follow-up.

Recruitment rate was 73% – of the 425 refusals, 226 were not willing to risk a volatile induction. During induction, excitatory movements and breath holding were more common with sevoflurane only (P < 0.01). Injection pain and hiccup were more common with propofol induction (P < 0.01). In the recovery room and the postoperative ward, both nausea and vomiting were more common with sevoflurane only (P < 0.01). This difference disappeared within 48 h. There was no difference between groups in the mental state on awakening, recovery time, time to discharge or overnight admissions; then was also no difference in pain between the four groups for each of the seven postoperative days (P < 0.01), nor any differences in concentration or forgetfulness. Patients took 6.5 days (95% CI: 6.0–7.0, n = 693) to resume normal activities. Patients who received sevoflurane only were more likely to recall an unpleasant induction and least likely to want the same induction method again (P < 0.01).

Differences in outcome between the four regimens are transient; sevoflurane is not an ideal sole agent for adult day case anaesthesia and, in this setting, patients base their preferences for future anaesthetics on the method of induction.

Because patients who are to undergo surgery must give their consent to planned postoperative care, clear and complete information on postoperative pain management should be given. The aim of this quality-of-care study was to evaluate by inquiry the impact of written information describing postoperative pain management on the quality and type of information retained, and patient participation in discussing and agreeing to the postoperative pain management programme during the presurgical anaesthesiology consultation.

Prospective before and after interventional surveys, each lasting 3 weeks and conducted at a 6-month interval (time required to prepare the written information), used a standardized anonymous questionnaire given to patients after the anaesthesiology consultation. Questions requiring a ‘yes’ or ‘no’ response assessed the quality of information and what information was retained by the patient, the extent of the patient’s interaction during the discussion with the anaesthesiologist and his/her agreement with the postoperative pain management programme.

Among the 180 before-group patients included, 16.7% reported receiving verbal information during the anaesthesiology consultation, none retained all seven principal side-effects of morphine, 14.4% considered the information to be thorough, 20.6% understood it, 16.7% claimed that it had helped them participate in the discussion and 14.4% concurred with the postoperative pain management programme. Compared to the before inquiry, significantly higher percentages of the 107 after-group patients (given written information before the anaesthesiology consultation) responded as having received verbal information during the anaesthesiology consultation (57.0%), retained morphine’s main side-effects (12.1%), deemed the information thorough (58.9%) and understandable (53.3%), had participated in the discussion (47.7%) and agreed with the postoperative pain management programme (51.4%).

Written information on postoperative pain management distributed before the presurgical anaesthesiology consultation improved the quality of information retained, facilitated discussion with the anaesthesiologist and patient agreement with the postoperative pain management programme.

To determine whether magnesium sulphate could induce controlled hypotension, reduce choroidal blood flow, provide a ‘dry’ operative field and could be compared with sodium nitroprusside in the recently raised issue of the use of hypotensive anaesthesia in eye surgery, i.e. for choroidal tumour surgery as the choroid is the most fragile and vascular structure in the eye.

Forty adult patients undergoing choroidal melanoma resection and anaesthetized with 2.5 mg kg−1 propofol, followed by a constant infusion of 120 μg kg−1 min−1, and remifentanil 1 μg kg−1, followed by a continuous infusion of 0.25 μg kg−1 min−1, were randomly assigned to two groups to receive either magnesium sulphate or sodium nitroprusside.

Controlled hypotension was achieved at the target systolic pressure of 80 mmHg within 107 ± 16 and 69 ± 4.4 s for magnesium sulphate and sodium nitroprusside, respectively. Choroidal blood flow decreased by 24 ± 0.3% and 22 ± 3.3% for magnesium sulphate and sodium nitroprusside, respectively. Controlled hypotension was sustained in both groups throughout surgery, and the surgical field rating decreased in a range of 80% in both groups. Sodium nitroprusside decreased pH and increased PaCO2. There were no postoperative complications in any of the groups.

Magnesium sulphate controlled hypotension, reduced intraoperative pressure and provided good surgical conditions for choroidal melanoma resection with no need for additional use of a potent hypotensive agent in adults.

Pumpless arteriovenous extracorporeal lung assist is increasingly used as a rescue therapy in acute respiratory distress syndrome. Arteriovenous extracorporeal lung assist is highly efficient in eliminating carbon dioxide and allows the application of ventilator techniques that prioritize lung protection and aim to reduce ventilator-induced lung injury and remote organ dysfunction.

Retrospective data analysis performed in a 12-bed university hospital ICU. In all, 22 patients with acute respiratory distress syndrome refractory to standard care were included. Arteriovenous extracorporeal lung assist as central part of a multimodal treatment concept was combined with tidal volume (VT) reduction below 4 mL kg−1 predicted body weight, a positive end-expiratory pressure titrated to optimize oxygenation and continuous axial rotation.

Hypercapnia was reversed within 24 h in survivors (39 mmHg (35–42) (median and interquartile range) vs. 65 mmHg (54–72), P < 0.05) and non-survivors (5.2 kPa (5.5–6.0) vs. 10 kPa (6.9–13.9), P < 0.05). Oxygenation was significantly improved in survivors after 24 h (PaO2/FiO2 ratio 20.7 kPa (17.4–22.7) vs. 11.7 kPa (7.3–20.8), P < 0.05). All patients required norepinephrine infusion and volume resuscitation. The overall complication rate was 23%, predominantly due to reversible lower limb ischaemia. One patient (5%) was permanently disabled due to amputation of a seriously injured lower leg 9 days after initiation of arteriovenous extracorporeal lung assist therapy; however, the patient survived without neurological deficits despite an initial oxygenation index of 4.4 kPa. The overall mortality rate was 27%.

A multimodal treatment concept with arteriovenous extracorporeal lung assist as its central part provides reversal of hypercapnia and stabilization of oxygenation. In an attempt to maximize lung protection and potentially reduce ventilator-induced lung injury, a further VT reduction below 4 mL kg−1predicted body weight combined with a high mean airway pressure and continuous axial rotation is safely possible.

Four percent gelatine is an alkaline compound due to NH2 groups, whereas 6% hydroxyethyl starch 130/0.4 (HES130) has acidic features. We investigated whether these solutions lead to differences in acid–base balance in pigs during acidaemia and correction of pH.

Anaesthetized pigs were randomized to HES130 or gelatine infusion (n = 5 per group). Animals received acid infusion (0.4 M solution of lactic acid and HCl diluted in normal saline) and low tidal volume ventilation (6–7 mL kg−1, PaCO2 of 80–85 mmHg, pH 7.19–7.24). Measurements were made before and after induction of acidaemia, before and after correction of pH with haemofiltration (continuous venovenous haemofiltration) and tris-hydroxymethylaminomethane infusion. We measured parameters describing acid–base balance according to Stewart’s approach, ketone body formation, oxygen delivery, haemodynamics, diuresis and urinary pH.

Acid–base balance did not differ significantly between the groups. In HES130-treated pigs, the haemodilution-based drop of haemoglobin (1.4 ± 1.0 g dL−1, median ± SD) was paralleled by an increase in the cardiac output (0.5 ± 0.4 L min−1). Lacking increases in cardiac output, gelatine-treated pigs demonstrated a reduction in oxygen delivery (149.4 ± 106.0 mL min−1). Tris-hydroxymethylaminomethane volumes required for pH titration to desired values were significantly higher in the gelatine group (0.7 ± 0.1 mL kg−1 h−1 vs. HES130: 0.5 ± 0.2 mL kg−1 h−1).

The buffer capacity of gelatine did not lead to favourable differences in acid–base balance in comparison to HES130.

Cardiac output is frequently monitored to maintain and improve cardiac function with the primary goal of adequate tissue perfusion. The pulmonary artery catheter is considered to be the gold standard although several non-invasive devices are being introduced and gaining attention. To evaluate the accuracy of the ultrasonic cardiac output monitor (USCOM)-1A (Pty Ltd, Coffs Harbour, NSW, Australia), a non-invasive cardiac output device including its capability to differentiate between different shock states in haemodynamically unstable ICU patients was used in this single-centre, prospective, observational study.

Cardiac output was measured with a pulmonary artery catheter and transcutaneously via a suprasternal approach with the USCOM-1A by continuous-wave Doppler ultrasound in 25 adult patients in a mixed medical and surgical ICU in a major teaching hospital in the Netherlands.

A total of 1315 USCOM-1A cardiac output measurements were performed. In order to reduce time-variability, the mean of five consecutive USCOM-1A measurements was calculated. Total 263 values were compared with 263 thermodilution cardiac output measurements performed with a pulmonary artery catheter. Data were analysed for systematic error, precision and correlation. Systematic and random errors were found. On average USCOM-1A values were 12% lower than thermodilution measurements (systematic error), while the random error was 17% (coefficient of variation). The error comprised an inter-operator variability of 3%, an inter-patient variability of 11% and residual variability of 15%. The correlation coefficient of the calculated cardiac index with the USCOM-1A and the pulmonary artery catheter was r = 0.8024 and 0.6438, respectively. Temperature and gender did not influence correlations. The learning curve for USCOM-1A skill acquisition was steep.

The correlation between the two techniques was acceptable, although relevant systematic and variable errors were detected. USCOM-1A provided adequate data to distinguish non-invasively different shock types in ICU patients.

Despite its popularity, serious complications do occur with percutaneous dilatational tracheotomy in the ICU. The associated risks in daily practice are probably underestimated and may reflect system flaws in training and team function. This study was performed to obtain an impression of risk perception and safety culture in connection with percutaneous dilatational tracheotomy in Norwegian ICUs.

The Medical Director or intensivist on-call in the 30 ICUs participating in the Norwegian Intensive Care Registry was telephone interviewed using a semi-structured questionnaire. Data on the practice of tracheotomy and a qualitative assessment of complications experienced during the last 2 years were collected. In the second part, percutaneous dilatational tracheotomy operators in two ICUs were questioned about their perception of risk with percutaneous dilatational tracheotomy and asked to assess their own abilities as percutaneous dilatational tracheotomy operators and the training they had undergone.

Of the 30 ICUs, 23 used percutaneous dilatational tracheotomy. The majority reported knowledge of severe complications like bleeding, hypoxia and tube dislodgment. Percutaneous dilatational tracheotomy-related deaths were also reported. Operators rated themselves relatively low and indicated the absence of any organized training. They acknowledged the known hazards related to percutaneous dilatational tracheotomy and suggested measures like fibreoptic guidance during the percutaneous dilatational tracheotomy and fewer operators with more experience as well as better team training, to improve patient safety.

Based on the frequent reporting of serious complications and the suggested safety precautions, we conclude that the percutaneous dilatational tracheotomy is considered a high-risk procedure and that there is still room for improving the safety of this much used ICU procedure.

The reliability of the Bispectral Index for evaluating and monitoring the depth of general anaesthesia in children is not as great as for that in adults. Therefore we analysed Bispectral Index performance in children by comparing changes in Bispectral Index values during a standardized and equipotent anaesthetic regimen using either halothane or sevoflurane for the induction and maintenance of general anaesthesia. Special interest was focussed on excitation during induction, and whether it was associated with simultaneous changes in Bispectral Index scores.

Twenty children (3–15 yr, ASA I–II) scheduled for general surgery were randomly allocated to either halothane (10 patients) or sevoflurane group (10 patients). Anaesthesia was induced by 3% halothane or 7% sevoflurane, either agent administered with 50% N2O in oxygen for 5 min, the period from the beginning of induction until intubation. Thereafter, anaesthesia was maintained by the respective volatile agent at 1 MAC (minimum alveolar concentration; in addition to 70% N2O in oxygen) and supplemented with remifentanil infusion adjusted to maintain the heart rate and mean arterial pressure to within 20% of the baseline values. Excitation at induction was defined as involuntary muscular movements.

Sevoflurane induction produced a more rapid depression in Bispectral Index than halothane, the mean difference being greatest (47 Bispectral Index score) at 105 s. Excitation occurred in three patients during sevoflurane induction, which coincided with increases in Bispectral Index values in two of the three patients. During the maintenance phase at 1 MAC, the Bispectral Index (mean ± SD) was 57±7 for halothane and 47±9 for sevoflurane (P < 0.05). The remifentanil doses did not differ between both groups.

In children, halothane anaesthesia was associated with higher Bispectral Index values than sevoflurane when administered at 1 MAC. Large individual variation in Bispectral Index occurred within both groups. Due to these limitations, one should be cautious when interpreting paediatric Bispectral Index data.

The elderly represent a wide and increasing patient population and significant numbers of elderly patients have chronic renal disease. This study aimed to investigate the neuromuscular effects of 0.6 mg kg−1 rocuronium under propofol anaesthesia in young adults and elderly patients with or without renal failure.

The neuromuscular effects of rocuronium 0.6 mg kg−1 under propofol anaesthesia were investigated in 40 patients with renal failure undergoing arteriovenous shunt surgery, of whom 20 were young adults (18–50 yr) and 20 were elderly (>65 yr) and in 40 patients with normal renal function undergoing peripheral venous surgery, of whom 20 were young adults and 20 were elderly. Neuromuscular transmission was monitored using acceleromyography. The times to recovery of the twitch (T1) to 25%, 50%, 75% and 90% and of the train-of-four ratio to 70%, and the recovery index were recorded.

The times to recovery of the first twitch to 25%, 50%, 75% and 90% and train-of-four to 70% and recovery index were found to be prolonged in both young and elderly patients with renal failure compared to those with normal renal function (e.g. T1 25%: 58.4 ± 20.2 and 80.1 ± 23.7 min vs. 32.8 ± 5.6 and 46.3 ± 9.0 min, respectively) (P < 0.05). These parameters were also prolonged in the elderly when compared with young adults in both the renal failure and the non-renal failure groups.

The neuromuscular effects of 0.6 mg kg−1 rocuronium under propofol anaesthesia were markedly prolonged in young and elderly renal failure patients compared to patients with normal renal function, and also in elderly patients with normal renal function compared with young adults.