The effectiveness of a balanced analgesia with buprenorphine ketoprofen-propacetamol for pain control during extracorporeal shock wave lithotripsy (ESWL) was evaluated in order to reduce the requirements for general anaesthesia. Two hundred and ninety-one consecutive patients were included in a randomized, placebo-controlled, double-blind study. Patients in each group received midazolam 5 mg pre-operatively as premedication. The subjects then received either placebo (group 1), buprenorphine 0.3 mg (group 2) or the combination buprenorphine 0.3 mg plus ketoprofen 100 mg and propacetamol 2 g (group 3) intravenously (i.v.) at a constant rate. The treatment was started 45 min prior to ESWL. Pain was assessed using a three-point verbal scale: (0)no pain; (1) moderate pain; and (2) intense pain needing general anaesthesia. The patients assessed their pain intensity on a 0–100 mm visual analogue scale. Only 69% of group 1 patients received ESWL with midazolam premedication. Buprenorphine provided good analgesia in 87% of group 2 patients, while the combination buprenorphine-ketoprofen-propacetamol was effective in 99% of group 3 patients (P<0.05). The incidence of nausea and vomiting was similar in the buprenorphine groups. No respiratory depression was reported. In conclusion, the buprenorphine-ketoprofen-propacetamol combination provided effective analgesia, allowing ESWL to be performed without the need for general anaesthesia.

The incidence of sore throat after the use of the laryngeal mask was assessed with a randomized trial in 839 patients. Sore throat occurred more often in women, older patients or after multiple insertion attempts. It was found that the frequency in women, but not in men, was lowered from 11.9% to 3.9% (P=0.012) by reducing intracuff pressure to the minimum required for an effective seal.

The antioxidant capacity of plasma taken from 10 patients before and during propofol anaesthesia was measured. Mean total plasma antioxidant activity fell from 1.73 to 1.64 mM L−1 trolox equivalents (P=0.047). This was caused by haemodilution since mean haemoglobin concentration fell from 13.0 to 12.5 g dL−1 (P=0.016). The time to 50% haemolysis (H50) of 10% red blood cell suspensions induced by 2,2'azo-bis(2-am-idinopropane) dihydrochloride (ABAP) was measured in blood from six patients. There was no change when red cells alone were studied, but when the patients' plasma was added to red cell suspensions (producing 10% plasma and 10% red cell suspensions), mean H50 increased from 291 to 308 min (P=0.049). Despite there being no overall increase in plasma antioxidant activity, the lipid soluble component of blood antioxidant activity appears to be increased by propofol.

Sixty children undergoing inguinal or urogenital surgery were allocated randomly to three groups to receive a caudal injection of either 0.125% bupivacaine 0.75 mL kg−1 with 0.5% midazolam 50 μg kg−1 (n=20) or with 1% morphine chlorhydrate 0.05mg kg−1 (n=20), or bupivacaine alone (n=20) after surgery under general anaesthesia. There were no significant changes in heart rate, blood pressure, respiratory rate or oxygen haemoglobin saturation values in all groups, and there were no significant differences in the incidence of vomiting and pruritus between the groups (P>0.05). Sedation scores were higher in the bupivacaine-midazolam and the bupivacaine-morphine groups than in the bupivacaine group at 8–12 h post-operatively (P<0.01). The durations of analgesia were 21.15±1.2 h in the bupivacaine-midazolam group, 14.50±1.6 h in the bupivacaine-morphine group and 8.15±1.3 h in the bupivacaine group. Differences between the bupivacaine-midazolam group and the bupivacaine group (P<0.001), the bupivacaine-midazolam group and the bupivacaine-morphine group (P<0.01), and the bupivacaine-morphine group and the bupivacaine group (P<0.01) were significant. It is suggested that caudal administration of a bupivacaine-midazolam mixture produces a longer duration of post-operative analgesia than a bupivacaine-morphine mixture and bupivacaine alone with sedation for 8–12 h post-operatively.

This study evaluates the prophylactic anti-emetic efficacy of granisetron, droperidol and metoclopramide, for the prevention of post-operative nausea and vomiting in female patients undergoing elective laparoscopic cholecystectomy. The patients were randomly assigned to one of four groups (n=30 for each group): granisetron 3 mg, droperidol 1.25 mg, metoclopramide 10 mg and placebo (saline). These medications were given immediately before the induction of anaesthesia. During the first 24 h after an-aesthesia, the incidence of post-operative nausea and vomiting was 13, 30, 33 and 37% after administration of granisetron, droperidol, metoclopramide and placebo, respectively (P>0.05, overall Fisher's exact probability test). No clinically important adverse effects were observed in either group. Our results suggest that granisetron is a better anti-emetic than droperidol or metoclopramide for the prevention of post-operative nausea and vomiting after laparoscopic cholecystectomy when compared with a placebo.

In clinical practice, anaesthetists encounter many patients who are on concurrent medication which may have the potential to interact with drugs used during anaesthesia. Many patients are receiving as many as a dozen drugs of various kinds, thus, increasing the risk of a drug interaction occurring. Unfortunately, anaesthetists tend not to report drug interactions which occur during anaesthesia—especially those of a minor nature such as flushing—and hence, the true number of drug interactions is unknown. We have developed a chart indicating the nature of important interactions that the anaesthetist may encounter.

The aim of this prospective, randomized and double-blind study was to assess the effects of a high dose of the analgesic tramadol administered at the conclusion of surgery on extubation time, sedation, and post-anaesthetic shivering. Forty adult patients, ASA physical status I or II, underwent laparoscopic surgery of about 1 h duration and received a standardized anaesthesia that was maintained with isoflurane in O2/N2O. Tramadol 3mg kg−1 (n=20) was administered intravenously at the beginning of wound closure, and was compared with saline (n=20). Post-anaesthetic shivering did not occur in any patient who received tramadol, whereas it occurred in 60% of the control group ( P<0.001). There were no adverse effects on time to extubation and sedation, and discharge-ready time was shorter in the tramadol group (P<0.05 compared with control). Pain scores in the post-an-aesthesia care unit (PACU) were statistically not different between the two groups, but significantly more supplemental medication was administered in the control group to treat shivering and/or pain. In conclusion, administration of a high dose of tramadol at the end of surgery prevents post-anaesthetic shivering without prolongation of extubation time, and shortens the PACU/discharge-ready time.

The purpose of this study was to analyse the clinical agreement between cardiac output measurements, obtained using a newly available continuous thermodilution technique, and the conventional intermittent bolus technique. Twenty-four cardiac surgical patients were intra-operatively monitored using both techniques. Additionally, two different averaging modes for the continuous thermodilution technique, either the previous 6 min (group 1) or 3 min (group 2) were compared. The mean difference between the continuous thermodilution technique and the intermittent bolus technique (bias), were calculated at eight selected time points. These ranged from −0.09 to 0.42 litres min−1 in group 1 and from −0.02 to 0.18 litres min−1 in group 2. There were significant differences at any time point between the groups. The relative error between continuous thermodilution and intermittent bolus techniques was <15% for the majority of measurements and was significantly higher in group 1 compared with group 2 just prior to cardiopulmonary bypass. Thus, the continuous thermo-dilution technique produced a clinically acceptable level of accuracy compared with the intermittent bolus technique measurements, especially when using an averaging mode for the previous 3 min.

Procalcitonin, a new innovative inflammation parameter is presently being evaluated in clinical studies. It has been shown to be increased markedly in patients with severe bacteria induced inflammation, septic shock, endotoxinaemia and multiple organ failure. In contrast, severe viral infections or inflammatory reactions of non-infectious origin as well as autoimmune or allergic disorders do not or only very moderately increase procalcitonin serum levels. Because procalcitonin is observed at significantly higher concentrations in bacterial infections, it might assist differentiation between these infections and other aetiologies of critical illnesses. Furthermore, pro-calcitonin correlates with the severity of infection and sepsis and thus could serve as a useful marker for monitoring surgical high risk patients. Procalcitonin may serve as a valid and sensitive indicator for bacterial infection with important diagnostic potential in the peri-operative period and in intensive care medicine.

Patient-controlled sedation (PCS) has been used during many different surgical procedures, both alone and as an adjunct to local or regional anaesthesia. Sedation with an admixture of propofol and alfentanil during transvaginal oocyte retrieval has been used successfully in this unit and this study was performed to assess the degree of patient acceptance of patient-controlled sedation, as other studies have indicated that self-administration of sedation may confer additional benefits on the patient, unrelated to the choice of sedation agent.

An admixture of 50 mL propofol 1% with alfentanil 2 mg was loaded into a Graseby 3300 patient-controlled analgesia pump and administered as increments of 0.3 mL with a zero lock-out interval. This method of sedation provided safe and highly satisfactory sedation for this group of patients with 55 of 56 patients indicating that they would opt for this type of sedation again. There was a very low incidence of over-sedation, and this sedation method is likely to produce a relaxed and co-operative patient for a wide variety of surgical procedures.

5-Hydroxytryptamine has wide-ranging effects on a number of physiological systems. In addition the exogenous application of 5-hydroxytryptamine or 5-hydroxytryptamine type drugs to tissue bath preparations has revealed the presence of a large and ever growing population of 5-hydroxytryptamine receptors. The discovery that 5-hydroxytryptamine is released at the neuromuscular junction raises the question as to whether it has a physiological function and whether or not applying low concentrations of 5-hydroxytryptamine transmitter would have any significant effect on twitch response at different rates of stimulation. Previous studies have demonstrated both facilitatory and depressant effects upon twitch responses in a variety of animal models. Single twitch responses of the rat phrenic nerve diaphragm preparation at non-fatiguing (0.3 Hz) and tetanic rates of stimulation (50 Hz) were recorded under conditions of indirect (nerve) stimulation at 4 g resting tension. The preparation was incubated with 0.5, 1, 2, 4, 16 μmol litre−1 concentrations of 5-hydroxytryptamine. The results of our investigations demonstrate that while low concentrations of 5-hydroxytryptamine have no effect upon the single twitch response at resting rates of stimulation (0.3 Hz), the initial single twitch and the subsequent eighteen responses immediately following a tetanus are facilitated (P<0.05). This work demonstrates that 5-hydroxytryptamine does have significant effects upon the neuromuscular junction under conditions of physiological compromise (following tetanus). These observations are the first step, therefore, in a series of studies aimed at identifying the resident 5-hydroxytryptamine receptors within the neuromuscular junction which will subsequently enable us to predict therapeutic effect or toxicity.

The molecular mechanism of volatile anaesthetic action on presynaptic glutamate release is not clear. An inhibitory effect on voltage-gated calcium channels has been proposed. The present study examines the effect of isoflurane on cytosolic free calcium and synaptic glutamate release from isolated nerve terminals. Synaptosomes from rat cerebral cortex were used. Glutamate was measured with a continuous fluorometric measurement in a spectrophotometer as the fluorescence of NADPH and calcium as the fluorescence of fura-2. Isoflurane reduced the calcium-dependent glutamate release evoked by membrane depolarization with 4-aminopyridine in an inversely dose-dependent manner. The glutamate release was reduced by 56, 43 and 36% in response to isoflurane 0.5, 1.5 and 3.0%, respectively (for all: P<0.05). Membrane depolarization evoked a rise in cytosolic free calcium of ≈34%. Addition of isoflurane (0.5, 1.5 and 3.0%) produced no significant change in cytosolic free calcium. These results indicate that the isoflurane-induced reduction in presynaptic glutamate release is caused by other mechanisms than blocking voltage-gated calcium channels. As the release is inversely dose-dependent, two or more mechanisms could be involved.

The isoflurane-saving and CO2-retaining effects of a charcoal filter were compared with a Siemens standard heat and moisture (HME) exchanger and an emptied specimen (dummy). Isoflurane was delivered during the inspiratory phase and consumption investigated at 10, 15 and 25 cycles min−1. The investigation was performed by ventilation with humidified air with a constant end-tidal CO2 and temperature. For a comparison, isoflurane was delivered in a conventional manner via the ventilator. The arrangement with a charcoal filter reduced the isoflurane consumption by a factor of 2.0−2.6, depending on ventilatory rate. Most of the saving was a result of the method of isoflurane delivery (factor 1.4−2.0), while adding the reflector gave a further reduction (factor 1.3−1.5). One circumstance that reduced the net efficiency of the charcoal filter was that it also reflected CO2; consequently, total minute ventilation had to be increased to maintain constant end-tidal CO2.

A 74-year-old woman was scheduled for surgical treatment of a carpal tunnel syndrome. An intravenous (i.v.) regional anaesthetic was performed using 1% prilocaine standard technique. Three minutes after injection of the local anaesthetic mild to moderate central nervous system symptoms developed, along with tachycardia, sweating and peri-oral paraesthesia. The evolution was favourable, no convulsions or other more serious events occurred. Despite showing adequate pressure inflation the tourniquet failed to accomplish its purpose. The patient recovered well without any sequelae.

Airway management is a major concern in Robin sequence, where micrognathia, glossoptosis and a cleft of the soft palate exist. The management of an infant with a potentially difficult airway is discussed where tracheal intubation was aided by the use of a 2.2-mm fibrescope mounted with a 3-mm endotracheal tube passed through a size 1 laryngeal mask airway.

The present report describes a case of cardiac arrest and subsequent death as a result of hyperkalaemia following the use of suxamethonium in a 23-year-old Malawian woman. Five days after the onset of the symptoms of meningitis, the patient aspirated stomach contents and needed endotracheal intubation. Forty seconds after injection of suxamethonium, bradycardia and cardiac arrest occurred. Attempts to resuscitate the patient were not successful. The serum level of potassium was observed to be 8.4 mequiv L−1. Apart from the reduction in the patient's level of consciousness, there were no signs of motor neurone damage or of any of the other known predisposing conditions for hyperkalaemia following the administration of suxamethonium. It is postulated that her death was caused by hypersensitivity to suxamethonium, associated with her 5-day immobilization.

Familial amyloid polyneuropathy (FAP) type I is a rare disease characterized by sensorimotor polyneuropathy, and autonomic nervous system and cardiac conduction system dysfunction. Severe bradyarrhythmia and hypotension may occur during anaesthesia and surgery in patients with the FAP type I. Only one report has been published of a patient with FAP type I who was managed with epidural anaesthesia. The present authors report a 38-year-old Japanese man with a permanent pacemaker because of advanced FAP type I who underwent rotation flap of the gluteus maximus muscle to cover a trophic ulcer in the sacral region under lumbar epidural anaesthesia. Ten millilitres of adrenaline (1:200 000) was injected around the ulcer prior to surgical manipulation. Neither bradycardia nor hypotension developed during the procedures. The haemodynamic changes under lumbar epidural anaesthesia in FAP type I are discussed.