Tracheal intubating conditions after induction with sevoflurane 8% in children. A comparison with two intravenous techniques.

We studied tracheal intubating conditions in 120 healthy children, aged 3-12 years, in a blinded, randomised clinical trial. Children were randomly allocated to one of three groups: group PS, propofol 3 mg.kg-1 and succinylcholine 1 mg.kg-1 (n = 40); group PA, propofol 3 mg.kg-1 and alfentanil 10 microg.kg-1 (n = 40); group SF, sevoflurane 8% in 60% nitrous oxide in oxygen for 3 min (n = 40). Tracheal intubating conditions were graded according to ease of laryngoscopy, position of vocal cords, coughing, jaw relaxation and movement of limbs. Overall intubating conditions were acceptable in 39 of 40 children in the propofol/succinylcholine group, 21 of 40 children in the propofol/alfentanil group and 35 of 40 children in the sevoflurane group. Children receiving propofol and succinylcholine or sevoflurane had better intubating conditions overall than those given propofol and alfentanil (p < 0.01). In conclusion, anaesthetic induction and tracheal intubation using sevoflurane 8% for 3 min is a satisfactory alternative to propofol with succinylcholine in children.

Untoward incident reporting in obstetric anaesthesia: a 6-month prospective study in Northern Ireland.

The marked reduction in the number of cases related to the provision of anaesthesia, included in the triennial Reports on Confidential Enquiries into Maternal Deaths in the UK, may limit the educational value of such reports for anaesthetists in the future. The collection, analysis and reporting of untoward events related to obstetric anaesthesia may provide an additional method of highlighting areas of clinical practice that could be improved. We report on a prospective study to identify such untoward incidents related to obstetric anaesthesia in the well circumscribed population of anaesthetists involved in this specialty in Northern Ireland. In total, 22 incidents were reported during the 6-month period of the study. A brief summary of each event is included along with a more detailed description from a sample of the reports. The advantages and disadvantages of untoward incident reporting are discussed, with recommendations made for a future survey.

Epidural infusion of alfentanil or diamorphine with bupivacaine in labour--a dose finding study.

Following induction of epidural analgesia with 0.375% bupivacaine, 120 healthy parturients were randomly assigned in a double blind fashion to one of eight infusion groups. All received 8 ml.h-1 of 0.125% bupivacaine either alone (control group), or with alfentanil at 133, 266 or 400 micrograms.h-1 (groups A1-A3) or with diamorphine at 133, 266, 400 or 533 micrograms.h-1 (groups D1-D4). Significantly longer top-up intervals were achieved with the two highest doses of both alfentanil and diamorphine when compared with bupivacaine alone (p < 0.01), making the minimum effective doses 266 micrograms.h-1 of alfentanil and 400 micrograms.h-1 of diamorphine. Perineal analgesia was better in all the opioid groups compared with the control group (p < 0.05). The intensity of motor block was greater in the control group (p < 0.05). The incidence of pruritus did not differ between groups. The highest dose of diamorphine caused significantly more nausea. No significant neonatal side-effects were demonstrated.

Epidural analgesia for labour using a continuous infusion of bupivacaine and alfentanil.

Seventy women who requested epidural pain relief in labour received a continuous epidural infusion at 8 ml h-1, which contained either 0.25% bupivacaine (n = 29), or a mixture of 0.125% bupivacaine and 0.005% alfentanil (n = 31), assigned randomly. Increments of 4 ml 0.25% bupivacaine were given on demand to prevent residual pain from uterine contractions. The two groups were compared for motor block of the lower limbs, number of increments required, type of delivery and neonatal Apgar scores. The group of women receiving the mixture of bupivacaine and alfentanil required between them seven increments; the group receiving bupivacaine alone required 15. One of the women receiving the mixture and eight of the women receiving bupivacaine alone had almost complete motor block. There were no differences in the mode of delivery or in the neonatal Apgar scores.

Anaesthetic monitoring: clinical practice in anaesthetic rooms and theatres.

Twenty anaesthetic rooms and operating theatres in Northern Ireland were visited in both 1990 and 1992. Data was collected on the availability and use of anaesthetic monitoring. In the anaesthetic rooms there were few pulse oximeters. In the theatres more monitors were available and in use. Some change in practice had occurred between 1990 and 1992, notably an increase in the monitoring of ventilation, and in the availability of printer facilities for documentation of anaesthetic records.

The effects of thiopentone and propofol on upper airway integrity.

One hundred and fifty-eight unpremedicated patients scheduled for elective surgery were allocated randomly to receive an unsupplemented induction dose of thiopentone or propofol. Visualisation of the vocal cords by standard laryngoscopy was possible more often after propofol (p less than 0.01). Pharyngeal and laryngeal reactivity was similarly depressed more frequently.

Reversal of neuromuscular block. Heart rate changes with slow injection of neostigmine and atropine mixtures.

The effect on heart rate of different rates of injection (10 seconds, 1, 3 and 5 minutes) of a fixed dose (neostigmine 2.5 mg and atropine 1.2 mg) and a weight-related dose (neostigmine 50 micrograms/kg and atropine 25 micrograms/kg) of neostigmine-atropine mixture given for the reversal of residual competitive neuromuscular block was studied in 196 healthy adult patients. In both series slow injection lessened and delayed the initial rise in heart rate. The subsequent fall in heart rate was less when the drugs were injected over 3 min compared with the 10 seconds and 1 minute injection groups but when given over 5 minutes there was a steady fall in heart rate, more so with the weight-related dose. It is recommended that a neostigmine and atropine mixture should be administered over 3 min.

Clinical evaluation of Org NC 45.

Org NC 45, a new non-depolarizing neuromuscular blocking drug, was evaluated in 200 adult patients. The drug was administered in doses of 0.1, 0.15 or 0.2 mg kg-1. Intubation could be satisfactorily carried out at around 90 s in 90% of patients. The duration of clinical relaxation varied from 23 min with 0.1 mg kg-1 and neuroleptanaesthesia to 71 min with 0.2 mg kg-1 and anaesthesia with halothane or enflurane. The duration of clinical relaxation following repeated administration of 2-3 mg was remarkably constant (between 17 and 20 min) thus showing lack of cumulation. The antagonism of residual block was prompt and easy following administration of neostigmine, and the drug lacked any significant cardiovascular effects as seen by routine monitoring.

Cerebrospinal fluid pressure changes during the induction phase of anaesthesia.

Cerebrospinal fluid pressure (CSFP) by lumbar puncture, systemic blood pressure (BP) and pulse rate (PR) were measured for 15 minutes during the induction phase of general anaesthesia in seven groups of six healthy female patients each. Intravenous drugs, thiopentopne 5 mg . kg-1, alfathesin 50 microliters . kg-1 and diazepam 0.5 mg . kg-1 given in 10 to 20 seconds caused a fall of CSFP and BP, whereas ketamine 2 mg . kg-1 and a three-minute induction with halothane three per cent, trichloroethylene one per cent, or methoxyflurane 0.75 per cent caused a sharp highly significant but short-lived rise of CSFP. Unlike ketamine, trichlorethylene and methoxyflurane, halothane caused a simultaneous significant fall of BP. To rule out apprehension as the cause of the rise of CSFP with inhalation agents a second challenge was given with similar concentrations of the vapours while patients were asleep. These still produced a sharp and significant rise of CSFP.

Comparison of Glycopyrrolate, atropine and hyoscine in mixture with neostigmine for reversal of neuromuscular block following closed mitral valvotomy.

Atropine, glycopyrrolate and hyoscine were compared in a mixture with neostigmine for the reversal of neuromuscular block in patients undergoing closed mitral valvotomy. Both atropine and glycopyrrolate were effective in counteracting the muscarinic effects of neostigmine. Glycopyrrolate was, associated with less initial increase in heart rate, a factor of importance in patients with mitral stenosis. The incidence of significant dysrhythmias was low in this small series. The control of secretions was better with glycopyrrolate. Administration of hyoscine was associated with unacceptable falls in heart rate and is not recommended.

Cerebral metabolism following brain injury. I. Acid-base and pO2 changes.

Acid-base parameters and oxygen tension were studied in arterial blood and lumbar CSF of 45 subjects in three groups of controls, head injuries, and postoperative cases. CSF in both groups of head injury and postoperative cases showed changes of metabolic acidosis with the arterial blood changes of respiratory alkalosis. Both groups had significant hypoxaemia. CSF acidosis is an indication of cerebral metabolic disturbance. It is proportional to the severity of brain damage, and permits a prognosis for further clinical progress. It is recommended that patients with severe brain lesions should be put on controlled ventilation to relieve them of respiratory overwork and to combat cerebral oedema.

Relation of precurarization to suxamethonium to provide ease of intubation and to prevent post-suxamethonium muscle pains.

Tubocurarine 0.05 and 0.07 mg.kg-1, gallamine 0.1 and 0.2 mg.kg-1 and pancuronium 0.01 and 0.02 mg.kg-1 given three minutes before suxamethonium 1.0, 1.5 and 2 mg.kg-1 in groups of 10 patients each (total 210 patients) to compare ease of tracheal intubation and incidence of post-suxamethonium muscle pain. These were compared with a control group of suxamethonium 1.0, 1.5 and 2 mg.kg-1 given alone after thiopentone 5 mg.kg-1. On analysis, tubocurarine 0.07 mg.kg-1 and suxamethonium 2 mg.kg-1 was the ideal combination with the best intubation conditions and the lowest incidence of post-suxamethonium muscle pains. The second best combination was gallamine 0.2 mg.kg-1 and suxamethonium 2 mg.kg-1. Pancuronium 0.01 mg.kg-1 and 0.02 mg.kg-1 in combination with suxamethonium 2 mg.kg-1 were satisfactory, although less efficient than the combination with either tubocurarine or gallamine.

Prolonged Q-T interval syndrome. Sudden cardiac arrest during anaesthesia.

A review of the literature concerning the causation of prolonged Q-T interval syndrome is presented. A fatal case, 50 years of age, with this rare entity is also reported, in whom a sudden cardiac arrest occurred 46 min after induction of anaesthesia. An outline for the successful anaesthetic management of patients with prolonged Q-T interval syndrome is suggested.

Effect of coagulating and cutting current on a demand pacemaker during transurethral resection of the prostate. A case report.

Electromagnetic interference from diathermy apparatus can be a real hazard in a patient with a demand pacemaker. A case is reported in which the cutting current of transurethral electrocautery deactivated an implanted pacemaker, while coagulating current did not alter pacemaker activity. Therefore frequent short bursts of cutting current were used for successful resection of the prostate. This case emphasizes the need for vigilant care of patients with demand pacemakers requiring transurethral resection.