Brugada syndrome--a review of the implications for the anaesthetist.

Brugada syndrome is characterised by specific electrocardiogram changes in the right precordial leads, a structurally normal heart and susceptibility to ventricular arrhythmias that may cause syncope or sudden death in otherwise fit young adults. Perioperative pharmacological and physiological changes may precipitate these events. Arrhythmias and symptoms typically occur at rest or sleep when vagal activity predominates. Although the condition is rare, the implications are serious and may result in death. Individual case reports describe diverse anaesthetic management. In this paper we critically appraise the literature to identify unifying features and determine whether specific management can be recommended. We found 18 clinical reports of anaesthesia including a total of 28 patients, most under general anaesthesia. Those with an implanted defibrillator should have it deactivated. All patients should have external defibrillator pads applied continuously throughout the perioperative period. Electrolyte imbalances should be corrected preoperatively. Propofol infusions for maintenance of general anaesthesia are probably safe if duration and dose are limited. Sevoflurane may be the preferred volatile anaesthetic. Autonomic changes, inadequate analgesia, light anaesthesia and postural changes should be all be minimised. The patient should be warmed or cooled to maintain normothermia. An isoprenaline infusion is advocated for intraoperative ST changes. Regional anaesthesia is possible if the dose is limited and systemic absorption restricted. Lignocaine is the drug of choice while bupivacaine is relatively contraindicated. Ropivacaine is possibly also not safe. Prolonged regional anaesthesia may therefore require continuous catheter techniques. Five-lead electrocardiogram monitoring and ST trend analysis should continue into the postoperative period.

Locally developed guidelines reduce immediate complications from percutaneous dilatational tracheostomy using the Ciaglia Blue Rhino technique: a report on 200 procedures.

Ciaglia Blue Rhino percutaneous dilatational tracheostomy is used as an aid to ventilatory weaning. It carries an immediate complication rate previously reported in 100 consecutive patients by Fikkers et al at 6% for "major" complications and 30% for "minor" complications. Mortality has been associated with the procedure. Our institution has performed dilatational percutaneous tracheostomy since 1998 and used the Blue Rhino technique since 2002. Consensus guidelines were developed following initial experiences. They focus on preoperative risk assessment including levels of ventilatory support and anatomical considerations, seniority of staff use of bronchoscopy and capnography and correction of coagulopathies. Following introduction of the guidelines we conducted an audit of the first 200 Ciaglia Blue Rhino tracheostomies performed. There was an immediate major complication rate of 3% and minor complication rate of 18%. No deaths occurred within 24 hours of the procedure. We conclude that applying our consensus guidelines produced an immediate complication rate for Ciaglia Blue Rhino percutaneous dilatational tracheostomy below published audits.

The tolerability and efficacy of a 6-month antituberculosis regimen containing rifampicin, isoniazid and pyrazinamide.

The tolerability and efficacy of a 6-month daily regimen of rifampicin (RMP), isoniazid (INH) and pyrazinamide (PZA) were tested in 130 hospitalized patients, mostly Black, with previously untreated pulmonary tuberculosis. PZA was discontinued at the end of the 2nd month. In 6 cases treatment was discontinued because of drug intolerance. The symptoms were severe rash, mild thrombocytopenia, deteriorating haematological and renal condition and in the remaining 3 patients hyperbilirubinaemia. Of the 125 patients who could be assessed bacteriologically, 110 were infected with organisms which were fully susceptible to INH and RMP, and 95% of their cultures and 77% of their smears had converted to negative after 2 months of treatment. Similar results were obtained for all but 2 of the 15 patients with drug-resistant bacilli. Cavitation of the lungs was reduced in 78% of the patients and the extent of other tuberculous lesions diminished in 87%.