Good measures for self-report of pain in children are important, particularly as other informants tend to underestimate children's pain. This paper describes the development of a new computer-assisted approach to assessment of pain in children. The child can represent a range of different types of pains on body maps, and use two scales to indicate the size of the pain and the ‘throb’ or intensity. Facial expressions of associated emotions can also be incorporated into the figure. A series of ‘pain pages’ is included in the program. The pages allow changes in pain to be tracked over time, building up a cumulative record. The child can also report on different experiences and give retrospective accounts. Potential applications are suggested, for example in facilitating communication with children who find it difficult to give a clear verbal account of their pain, due to emotional difficulties, language or disability. Research directions are outlined.

Anaesthetic agents have been implicated in the development of postoperative pneumonia, but the direct effect of volatile anaesthetics on bacterial growth has given contradictory results. The effects of isoflurane on the growth of Staphylococcus aureus and Escherichia coli were investigated under conditions similar to those of clinical practice, using standardized microbiological methods. An open anaesthetic circuit was adjusted to the normal ventilatory settings of an adult patient. A spray, installed on the inspiratory side of the circuit, ensured the delivery of isoflurane at 1.5 minimal alveolar concentration. The bacterial strains studied were both wild-type and reference strains. Bacterial inoculums were prepared to obtain a bacterial exponential growth of 103 colony-forming units per mL in 10mL of nutritive broth. Each strain was studied with and without exposure to isoflurane and measured by the usual criteria of bacterial growth, and by bacterial regrowth after exposure to isoflurane. Under experimental conditions close to clinical practice, exposure to isoflurane did not alter bacterial growth of S aureus and E. coli, or their bacterial regrowth when isoflurane exposure is over.

Recently, it was suggested that peripherally-mediated analgesia can be accomplished by the intra-articular delivery of the mu-opioid morphine or of the a2-agonist clonidine. This clinical study assesses the potential peripheral analgesic effect of the combination of morphine and clonidine after intra-articular administration. Sixty patients (American Society of Anesthesiologists status I or II) undergoing arthroscopic repair of the knee during general anaesthesia were randomized to receive after operation, in a double-blind manner, either 1 μg morphine intra-articularly (group 1); 150 μg clonidine intra-articularly (group 2); or 1 μg morphine + 150 μg clonidine intra-articularly (group 3); or normal saline intra-articularly (group 4) in a volume of 30 mL, respectively. Visual analogue pain scores (VAS), duration of analgesia as defined by first demand for supplemental analgesics, subsequent 24 h consumption of postoperative supplementary supplementary analgesics, and patient satisfaction were evaluated. Co-administration of morphine + clonidine (group 3) resulted in a significant VAS reduction at 2 h after injection compared with the other groups. There was a tendency towards a lower need for supplementary rescue analgesia and towards a more prolonged analgesia in group 3 (211 min ± 224 min SD) compared with group 1 (173 min ± 197 min SD) and group 4 (91 min ± 21 min SD). More patients were very satisfied with the postoperative analgesic regimen receiving the combination of morphine and clonidine (group 3) at 24 h postoperatively. Thus we conclude, that the peripheral co-delivery of an opioid and an a2-agonist will result in improved postoperative pain relief, when compared with each single agent given alone.

We prospectively evaluated the effects of pneumoperitoneum and reverse Trendelenburg position on cardiopulmonary function in 20 ASA physical status II–III morbidly obese patients (body mass index > 35 kg m−2) undergoing laparoscopic gastric banding. After general anaesthesia was induced, patients' lungs were ventilated using intermittent positive pressure ventilation (at measurement times, the following parameters were used: tidal volume 12 mL kg−1 ideal body weight, respiratory rate of 12 bpm, an inspiratory to expiratory time ratio of 1 : 2). Haemodynamic variables, blood gas parameters, and lung/chest compliance were recorded: in the supine position, after induction of general anaesthesia (T0, baseline) and induction of pneumoperitoneum (T1); after placing the patient in a 25° reverse Trendelenburg position (T2); during the surgical time (T3); before deflating the abdomen (T4); after pneumoperitoneum resolution (T5), and before the end of anaesthesia, with the patient supine (T6). The PaO2, PaO2/FiO2 ratio, and lung/chest compliance decreased during the study. After the pneumoperitoneum had been resolved, lung/chest compliance but not oxygenation parameters returned to baseline values. The arterial to end-tidal CO2 tension difference progressively increased from 0.38 ± 0.3 kPa (2.85 ± 2.25 mmHg) (T0) to 0.63 ± 0.3 kPa (4.73 ± 2.25 mmHg) (T6). In morbidly obese patients, undergoing laparoscopic gastric banding, a CO2 pneumoperitoneum markedly affected gas exchange and lung/chest compliance, while positioning the patient in a 25° reverse Trendelenburg position had no beneficial effects.

To use end-tidal PCO2 as a non-invasive estimate of arterial PCO2, one adds a nominal value, representing the arterial–end-tidal PCO2 difference. How much does one add? We hypothesized that, halving the ventilator rate and simultaneously doubling tidal volume, the immediate change in end-tidal PCO2 would be proportional to the original arterial-end-tidal PCO2 difference. We ventilated 31 patients at 20 breaths per minute (bpm), sampled arterial blood, and changed the rate to 10 bpm. The change in end-tidal PCO2 was, as hypothesized, positively correlated to the original arterial–end-tidal difference at 20 bpm (r = 0.64). End-tidal PCO2 increased in 23 patients. Thus, in theory, this method could offer some improvement in the estimate of arterial PCO2 from end-tidal. However, because of the considerable spread of values, a separate study is needed for verification

The effects of inhalational anaesthetic agents on renal sympathetic nerve activity (RSNA) were compared in anaesthetized rabbits. Concentrations of 6% desflurane, 1.2% isoflurane, and 2.4% enflurane increased mean RSNA up to 32, 36 and 44% while higher concentrations, of 12, 2.4 and 3.2% depressed it by 42, 83 and 5%, respectively. For halothane RSNA was unchanged up to 0.8% and decreased by 36% at 1.6% concentration. Nitrous oxide increased RSNA up to 28% at 50% concentration. Maximum reductions in mean arterial pressure (MAP) were 60% for both 2.4% isoflurane and 3.2% enflurane, 50% for 12% desflurane and 1.6% halothane, while 70% nitrous oxide increased MAP by 22%. In conclusion, unlike the entirely depressive effects of halothane, the effects of desflurane, isoflurane and enflurane were biphasic involving excitation at lower concentrations and depression of RSNA and a reduction in MAP at higher concentrations. Nitrous oxide caused increases in both RSNA and MAP.

This prospective, double-blind, randomized study assessed effect of pre-emptive peritonsillar block in 30 ASA–I children, aged 6–12 years, of both sexes, scheduled for tonsillectomy. Patients were divided into three groups: those in group I received a sham block, whereas peritonsillar blocks with bupivacaine 0.25% were given to the children before tonsillectomy (group II) or immediately after surgery had been completed (group III). Constant pain, pain on swallowing, blood glucose, serum epinephrine and norepinephrine concentrations were measured immediately after surgery and 4 h after operation. Patients in group I experienced more pain (P < 0.05) than those in groups II and III, both in the immediate postoperative period and over the next 4 h. Patients in groups II and III experienced similar pain (P > 0.05). The pain experienced when water was swallowed was similar to that of the constant pain. The rise of serum norepinephrine concentration in group II was significantly less (P < 0.05) compared to groups I and III. We found both pre-emptive and postoperative block to be equally effective in treating postoperative pain, with pre-emptive block being more effective in preventing the rise in norepinephrine concentration.

A 45-year-old man with cryptorchism, who was known to suffer from generalized myasthenia gravis, was admitted to hospital for surgical treatment using laparoscopy. Such minimally invasive surgery requires good muscle relaxation. However, the use of neuromuscular blocking agents in patients with myasthenia gravis may lead to prolonged apnoea after operation, thus necessitating mechanical ventilation of the lungs. We used a combination of general anaesthesia (with desflurane), and epidural anaesthesia (with the amide local anaesthetic ropivacaine) to obtain excellent abdominal relaxation during surgery. Tracheal extubation was possible immediately after the operation and no adverse effects were observed. The patient was discharged from hospital on the second day after operation. The combination of regional and general anaesthesia for minimally invasive surgery in this patient permitted safe anaesthetic management.

We describe the satisfactory use of combined spinal epidural (CSE) anaesthesia in the management of a 29-year-old paraplegic woman, with a spinal cord lesion at the T7 level, suffering from episodes of autonomic hyper-reflexia, during elective Caesarean section.