Quality assurance in anaesthetic practice: comparison between two methods in detecting complications.

BACKGROUND: Reliable identification and documentation of complications is an essential part of a well-functioning quality system (QS) in anaesthetic practice. The criteria for the complications have to be appropriate. The QS of Kuopio University Hospital fulfils the ISO 9002 standard. The validity of the recordings in the QS was ascertained by comparing the routine recordings with external assessment. METHODS: Three types of complications were predefined: minor, severe and those specific for regional anaesthesia. A total of 1006 anaesthetic charts, including general, regional and intravenous anaesthesia, were randomly selected and retrospectively screened by an external assessor. The retrospective assessment of complications was compared to the recordings in the data management system for operative procedures (DMS) as a part of routine quality assurance. Cohen's kappa statistics was used to indicate agreement between two raters. RESULTS: Both methods identified complications in 115 procedures (11.4%). The methods, however, did not identify complications in same procedures. There was a fairly close agreement (P < 0.001) between the methods in detecting all (Cohen's kappa 0.72), minor (0.67) and severe (0.66) complications and those specific for regional anaesthesia (0.78). Fifty-eight complications were detected either by retrospective assessment or routine reporting, i.e. the two raters disagreed in 58 complications. Thirteen severe complications recorded in the DMS could not be retrospectively identified. The agreement did not depend on ASA class, the urgency or the length of procedures or on the type of anaesthesia. CONCLUSIONS: The agreement between external assessment and routine reporting was fairly good, however, there were still some relatively large differences. The selection and definitions of complications need to be reassessed.

Laparoscopic or open cholecystectomy: a prospective randomised trial to compare postoperative pain, pulmonary function, and stress response.

OBJECTIVE: Open cholecystectomy (OC) has been superseded by laparoscopic cholecystectomy (LC) for the treatment of cholelithiasis, although this fashion has not been validated by prospective studies. Our aim was to compare the two techniques. DESIGN: Prospective, randomised, open study. SETTING: University hospital, Finland. PATIENTS: 49 patients who required cholecystectomy for cholelithiasis confirmed by ultrasound. INTERVENTIONS: 49 patients were randomly allocated to LC (n = 27) or OC (n = 22): 25 and 22, respectively, eventually had the operation. LC was done using a four-trocar technique, and OC through a transverse right subcostal incision, as short as possible. MAIN OUTCOME MEASURES: Length of hospital stay and the duration of the sick leave were the primary outcome measures. Secondary outcome measures were: postoperative pain evaluated by visual analogue scale (VAS) and the need for opioids; pulmonary function measured by forced vital capacity (FVC), forced expiratory volume in one second (FEV1), peak flow velocity (PEFV), and arterial oxygen tension (PaO2), and endocrine stress measured by plasma catecholamines, cortisol and glucose concentrations. RESULTS: The median (range) hospital stay was significantly shorter after LC than OC, being 2.0 (1-15) compared with 4.5 (2-19) days p < 0.01. The duration of sick leave was also significantly shorter after LC than OC, being 14 (7-17) compared with 29 (4-34), p < 0.01. Patients had significantly less postoperative pain after LC than OC as reflected by the need for opioids. Pulmonary function and arterial oxygen tension deteriorated significantly less after LC than OC. The stress response was equal. There were three documented complications, one pneumonia after LC and two wound infections after OC. CONCLUSIONS: LC gives significantly better results in terms of less postoperative pain, better pulmonary function, better arterial oxygenation, and shorter hospital stay and duration of sick leave.

No difference between bupivacaine in 0.9% and 8% glucose for spinal anaesthesia in small children.

BACKGROUND: Baricity is one of the most important factors to influence the characteristics of distribution of the local anaesthetic and hence success and spread of the blockade. Bupivacaine is rendered hyperbaric by adding glucose. The effect of differing degrees of hyperbaricity remains to be evaluated. METHODS: Two hyperbaric bupivacaine solutions, in 0.9% and in 8% glucose, for spinal anaesthesia were investigated in 60 children, aged 1-7 years, in a double-blind, randomised, parallel group, prospective study. The children were premedicated with diazepam orally. Bupivacaine 5 mg ml(-1) in either 0.9% or 8% glucose was injected in a dose of 0.4 mg kg(-1). Maximum cephalad extent and regression of sensory block were tested by transcutaneous electrical stimulation. RESULTS: Success rate, spread and duration of sensory block were similar in both groups. Only one child required a single dose of fentanyl during surgery. The highest median level of sensory block was T3 (T2-T7) (median (10th/90th percentiles)) in both groups. Time to reach T10 did not differ between the groups. The incidence of adverse effects was similar. Atropine was administered to one child in each group to treat bradycardia and 6 children (10%) experienced shivering. One child in each group vomited once. CONCLUSION: These results demonstrate that bupivacaine in 0.9% glucose and in 8% glucose solutions are equally suitable for spinal anaesthesia in small children. Similar success rate, spread and duration of the sensory and motor block are achieved with both baricities of bupivacaine.

Needle design does not affect the success rate of spinal anaesthesia or the incidence of postpuncture complications in children.

BACKGROUND: In adults, pencil-point spinal needles are believed to be less traumatic and therefore to be superior compared to cutting-point needles with respect to success rate and postpuncture complications. The aim of this randomised, parallel groups and prospective study was to record the success rate and to evaluate the incidence of complications following spinal anaesthesia with the two types of needles in children. METHODS: We studied 215 children aged 1 to 18 years. A 25-gauge needle was used in children up to 7 years (n=96) and a 27-gauge needle in older children (n=119). During lumbar puncture with either a cutting-point (n=109) or a pencil-point (n=106) spinal needle, we recorded puncture characteristics and the success of cerebrospinal fluid (CSF) aspiration. Hyperbaric bupivacaine 5 mg ml(-1) at a dose of 0.3-0.4 mg kg(-1) was used for the spinal anaesthesia. The incidence of postdural puncture complications was recorded from diaries completed by the children and parents one week after the lumbar puncture. RESULTS: The success rate of the spinal anaesthesia was 97% without difference between the needles. The success rate was higher when the aspiration of CSF was easy compared to if it was difficult (98% vs. 88%, P=0.02). Two hundred and seven diaries were returned (97%). Twenty-four children developed a headache, 8 of which were classified as a postdural puncture headache (PDPH), 6 with the cutting-point needle and 2 with the pencil-point needle (n.s.). Nine children developed signs of transient radicular irritation with no difference between the needles. CONCLUSION: Both types of spinal needles can be used in children, and a free aspiration of CSF results in a high success rate of the spinal block. Postpuncture complications are as common in children as in adults.

Hyperbaric bupivacaine for spinal anaesthesia in 7-18 yr old children: comparison of bupivacaine 5 mg ml-1 in 0.9% and 8% glucose solutions.

We have compared two hyperbaric bupivacaine solutions for spinal anaesthesia in 7-18-yr-old school-aged children in a double-blind, randomized, parallel group, prospective study. Children were premedicated with diazepam orally. Half of the patients were sedated with either midazolam or thiopental. After lumbar puncture with a 27-gauge spinal needle, bupivacaine 5 mg ml-1 in either 0.9% or 8% glucose was injected in a dose of 0.3 mg kg-1. Maximum cephalad spread and regression of block were tested by transcutaneous electrical stimulation. Success rate, spread and duration of sensory block were similar in both groups. The highest median level of sensory block was T4 (10-90th percentiles T1-T7) in the 0.9% glucose group and T4 (T1-T5) in the 8% glucose group. Time to two segment regression of block was 83 (50-143) min in the 0.9% glucose and 85 (53-150) min in the 8% glucose group. The incidence of adverse effects was similar. Six children were given etilefrin to treat hypotension and six atropine for bradycardia. Nausea was associated with a high level of block. Shivering was detected in 16 children.

Intravenous ketoprofen and epidural sufentanil analgesia in children after combined spinal-epidural anaesthesia.

BACKGROUND: Epidural opioid analgesia has become more popular for postoperative pain treatment in children. Epidural opioids are associated with adverse effects such as respiratory depression, excessive sedation, protracted vomiting, urinary retention and pruritus. Following minor surgery, ketoprofen has a synergistic effect with opioids, resulting in an improved analgesia without increase in incidence of adverse effects. To see whether this is also true following major surgery, we compared the effect of i.v. ketoprofen and placebo as an adjuvant to epidural sufentanil analgesia. METHODS: A prospective, randomised, double-blind, placebo-controlled, parallel-group study design was used in 58 children, aged 1-15 years, receiving a standardised combined spinal-epidural anaesthesia. Intravenous ketoprofen or saline was provided as a bolus and a continuous infusion in addition to epidural sufentanil infusion, which was adjusted as clinically required. Epidural bupivacaine was used for rescue analgesia. The study drug infusion was discontinued when pain scores were <3 on a 0-10 scale for 6 h with an epidural sufentanil infusion rate of 0.03 microg kg(-1) h(-1). RESULTS: Children in the ketoprofen group received less rescue analgesia (none/29 vs. 8/29 children in the placebo group). In the ketoprofen group, criteria to discontinue epidural sufentanil were achieved more often (14 vs. 6 children) before the end of the 72 h study period. Less children in the ketoprofen group suffered pruritus (13 vs. 4). The incidence of nausea/retching and vomiting was similar (11 vs. 12) in both groups. CONCLUSION: In this study, ketoprofen as a background analgesic to epidural sufentanil provided improved postoperative analgesia and reduced incidence of adverse effects of the epidural opioid.

The effect of intravenous ketoprofen on postoperative epidural sufentanil analgesia in children.

UNLABELLED: We compared the effect of IV ketoprofen and placebo as an adjuvant to epidural sufentanil analgesia after major surgery. We used a prospective, randomized, double-blinded, placebo-controlled, parallel-group study design in 54 children aged 1-15 yr who received a standardized anesthetic. Either IV ketoprofen or saline was administered in addition to an epidural sufentanil infusion, which was adjusted as required clinically. The study drug infusions were discontinued when pain scores were <3 on 0-10 scale for 6 h at a sufentanil infusion rate of 0.03 microg x kg(-1) x h(-1). Children in the ketoprofen group had a better analgesic effect, as shown by decreased need for sufentanil (mean [10th-90th percentiles] 8.3 [3.1-15.1] microg/kg vs 12.5 [6.2-18.9] microg/kg; P = 0.002) and earlier possibility to discontinuation of the epidural sufentanil (11 [46%] vs 3 [13%]; P = 0.014) before the end of the 72-h study period. In the ketoprofen group, median (range) pain scores were lower during activity at 24 h (2 [0-5] vs 5 [0-7]; P = 0.01) and at 72 h (0 [0-3] vs 2 [0-6]; P = 0.033), and fewer children had inadequate pain relief during activity at 24 h (0 vs 5; P = 0.037). Children who received ketoprofen required fewer infusion rate adjustments (12 [4-20] vs 17 [6-42]; P = 0.016). In the ketoprofen group, the incidence of desaturation (1 [4%] vs 6 [26%]; P = 0.035) and fever (3 [12%] vs 11 [48%]; P = 0.008) was less than that in the placebo group. We conclude that ketoprofen improved postoperative pain in children. IMPLICATIONS: We compared the effect of the IV nonsteroidal antiinflammatory drug ketoprofen versus placebo as adjuvants to epidural opioid analgesia with sufentanil. The continuous IV nonsteroidal antiinflammatory drug improved pain after major surgery in children receiving an epidural opioid. Although ketoprofen reduced epidural sufentanil requirements, the incidence of opioid-related adverse effects was not changed.

Ketorolac, diclofenac and ketoprofen are equally efficacious for pain relief after total hip replacement surgery.

We have compared the efficacy of ketorolac 30 mg i.v. followed by infusion at a rate of 90 mg/15.5 h, with that of diclofenac 75 mg followed by infusion of 75 mg/15.5 h or ketoprofen 100 mg followed by infusion of 100 mg/15.5 h, on postoperative pain in 85 patients after hip replacement surgery under spinal anaesthesia in a prospective, double-blind, randomized study. Supplementary analgesia was administered during the 16-h postoperative period with bolus doses of fentanyl delivered by a patient-controlled analgesia system. Mean total consumption of PCA-administered fentanyl was 890 (SD 400) micrograms in the ketorolac group, 920 (550) micrograms in the diclofenac group and 850 (350) micrograms in the ketoprofen group (ns). Median VAS scores were low over the entire study in each group and there was no significant difference between groups. No serious adverse events were recorded.

Postdural puncture headache and transient neurologic symptoms in children after spinal anaesthesia using cutting and pencil point paediatric spinal needles.

BACKGROUND: In the last decade the use of spinal anaesthesia (SA) in paediatric anaesthesia has increased. In adults, pencil point spinal needles are supposed to be less traumatic and hence to be superior compared with cutting point needles in respect of postpuncture complaints. In children, the use of spinal needles with a special tip design have not been compared. The aim of this study was to study the clinical utility and postpuncture characteristics of four newly designed spinal needles in paediatric surgery. METHODS: In this open-randomised, parallel groups, prospective study we compared the puncture quality, success rate and postpuncture characteristics in 200 children aged 2 to 128 months. Two cutting point needles; a 50-mm-long 25G Quincke and a 25-mm-long 26G Atraucan were compared with two pencil point needles; a 37-mm-long 27G Whitacre and a 35-mm-long 24G Sprotte. The children were premedicated with oral diazepam and those anxious or uncomfortable after premedication were sedated with i.v. thiopentone or propofol. Bupivacaine 5 mg ml-1 0.3-0.5 mg kg-1 was used for the SA. RESULTS: The spinal puncture was successful with one or two skin punctures in 96% of children. The cutting point needles were easier to insert through the skin and ligaments (P = 0.001) but the pencil point needles gave a better (P = 0.001) indication of the dural passage. The success rate of the SA was 91% without differences between the needles. Five patients were given general anaesthesia and 13 children a single dose of i.v. fentanyl/sedative. The spinal block was completed in less than 3 min in 96% of the cases without differences between the needles. Seventeen children developed a headache, 10 of which were classified as a postdural puncture headache (PDPH), 3 with the Sprotte, 3 with the Quincke and 4 with the Atraucan needles. The youngest child developing PDPH was a 12-month-old boy. Eight of the PDPH were mild and 2 moderate. Ten children developed a low back pain, 2-3 in each study group. Three children in the pencil point groups developed signs of transient radicular irritation. CONCLUSION: SA using bupivacaine and the study needles produced smooth and safe anaesthesia for paediatric surgery with a high success rate. PDPH after SA is as common in children (5%) as in adults although most often mild and short lasting. SA using bupivacaine can cause transient radicular irritation.

Spinal anaesthesia for paediatric day-case surgery: a double-blind, randomized, parallel group, prospective comparison of isobaric and hyperbaric bupivacaine.

We have compared bupivacaine 5 mg ml-1, either isobaric in saline 0.9% or hyperbaric in 8% glucose, for spinal anaesthesia in 100 children, aged 2-115 months, in a double-blind, randomized, parallel group, prospective study. Children were premedicated with diazepam 0.5 mg kg-1 orally. Seventy-two children were sedated before, and 25 children after, lumbar puncture, with either propofol or thiopental (thiopentone). After lumbar puncture in the lateral decubitus position with a 24-27-gauge paediatric spinal needle, isobaric or hyperbaric bupivacaine 5 mg ml-1 was injected in a dose of 0.3-0.5 mg kg-1 using a blinded procedure. Maximum cephalad extent of the block was tested by transcutaneous electrical stimulation. The success rate of the block was greater with hyperbaric bupivacaine (96%) compared with isobaric bupivacaine (82%) (P = 0.025, 95% confidence intervals (CI) 0-28%). Intense motor block was associated with adequate sensory block. Spread and duration of sensory block showed a similar wide scatter in both groups. The highest median level of sensory block was T4 (range T1-12) in the isobaric group and T4 (T1-7) in the hyperbaric group. Times to two segment regression of block were similar: 80 (55-190) min in the isobaric and 80 (30-190) min in the hyperbaric group. Cardiovascular stability was good. Etilefrin was administered to one child to treat hypotension and atropine to one child to treat bradycardia. The study gave an impression of a delayed onset time of spinal block, as most of the nine children who required either fentanyl or a sedative for a mild reaction to skin incision had complete block when transferred to the recovery room after operation. Five children developed a mild, position-dependent headache.

Epidural analgesia with bupivacaine does not improve splanchnic tissue perfusion after aortic reconstruction surgery.

Inadequate splanchnic tissue perfusion is relatively common during and after aortic surgery. We hypothesized that vasodilation caused by thoracic epidural analgesia improves splanchnic blood flow and tissue perfusion after aortic surgery. In this prospective, randomized, controlled study, we studied 20 patients undergoing elective aortic-femoral or aortic-iliac reconstruction surgery. Gastric and sigmoid colon mucosal PCO2 and pH were measured during surgery. An epidural bolus of bupivacaine 40 mg followed by infusion of 15 mg h-1 was started after operation in 10 patients. After operation, splanchnic blood flow and gastric and sigmoid colon mucosal PCO2 and pH were measured before and 2 h after the start of epidural analgesia. During surgery, the gastric mucosal-arterial PCO2 difference remained stable, whereas the sigmoid mucosal-arterial PCO2 difference increased during aortic clamping but returned to pre-clamping values after declamping. After operation, epidural analgesia had no effect on gastric or sigmoid mucosal-arterial PCO2 differences or on splanchnic blood flow.

Comparison of 25 G and 29 G Quincke spinal needles in paediatric day case surgery. A prospective randomized study of the puncture characteristics, success rate and postoperative complaints.

A comparison of a 25 G with a 29 G Quincke needle was performed in paediatric day case surgery. Sixty healthy children aged 1 year to 13 years were randomly allocated to have spinal anaesthesia with either 25 G or 29 G Quincke needle without an introducer needle. There was a failure rate of 10% with the 29 G spinal needle compared with 0% with the 25 G needle. The time needed to perform dural puncture was shorter using 25 G than 29 G needle, 22 (+/- 31)(SD) vs 59 (+/- 63) s. The time taken for cerebrospinal fluid to appear at the needle hub was also longer, 4 (+/- 3) vs 8 (+/- 5) s. The number of puncture attempts was similar, 1.2 (+/- 0.6) vs 1.4 (+/- 0.8), with 25 G and 29 G needle. Low back pain, 5 vs1, and nonpositional headache, 2 vs 4, after 25 G and 29 G needles, respectively, were the most frequent postoperative complaints. Mild postdural puncture headache occurred in one eight year old male patient in the 25 G group. In conclusion, lumbar puncture without introducer needle was possible with both needles. The puncture characteristics favoured the 25 G needle. A shorter needle could partly alleviate the difficulties with the 29 G needle.

Does morphine premedication influence the pain and consumption of postoperative analgesics after total knee arthroplasty?

Evidence of pre-emptive analgetic effect of opioid would offer great potential benefit to patients with postoperative pain, a better pain relief with less opioid. The aim of this double blind randomised trial was to study the effect of intramuscular morphine premedication on postoperative pain. Forty-one patients undergoing total knee arthroplasty were randomly allocated to four groups. Two groups received epidural morphine, 4 mg immediately after operation and 3 mg ten hours later, and two groups the same volume of saline. All patients had access to intravenous PCA-fentanyl. One epidural morphine and one epidural saline group (PreEpiMo and PreMo, respectively) received morphine, 0.14 mg/kg i.m. as premedication. Pain was measured with a visual analogue scale (VAS). Respiration was monitored by means of pulseoximetry, arterial blood gas analysis and rate of breathing. Morphine premedication reduced postoperative pain in the immediate postoperative period in patients with epidural placebo (PreMo), but the effect was absent in patients with PreEpiMo. Epidural morphine (EpiMo) provided stable analgesia with reduced need of PCA-fentanyl. Two patients (10%) (one in EpiMo and one in PreEpiMo) developed respiratory depression requiring naloxone treatment. The dosage of epidural morphine used in this study was a likely explanation of this depression. Nausea, vomiting, itching and urinary retention were the most frequent side effects without significant differences between the groups. In conclusion, morphine premedication had a temporary rest effect on the postoperative pain. Epidural morphine provides a better analgesia than intravenous PCA-fentanyl.

Comparison of spinal anaesthesia with epidural anaesthesia in paediatric surgery.

202 children aged 2 months to 17 years, undergoing elective paediatric operations below the umbilicus, were allocated randomly to receive either spinal (SA) or epidural anaesthesia (EA). SA was more efficacious since 8 children of 102 needed supplementation with general anaesthesia, in contrast to EA where 24 children of 100 were supplemented with general anaesthesia and 6 with fentanyl. The haemodynamic stability was maintained during EA, whereas during SA 6 patients were given medication to increase heart rate/blood pressure. EA provided longer pain relief than SA in the recovery room. The incidence of postoperative side effects was similarly low following SA and EA. Complaints after discharge were also similar. General weakness (7% vs 8% after SA and EA, respectively), low back pain (6% vs 6%), headache (7% vs 4%), fever (6% vs 4%) and positional headache (PDPH) (5% vs 3%) were the most frequent side effects. PDPH was only observed following SA in children aged 11 years or older. Following EA, PDPH was also observed in the younger age group after accidental dural puncture. In conclusion, we prefer SA for minor paediatric operations due to its high efficacy.

Breathing pattern and gas exchange in emergency and elective abdominal surgical patients.

OBJECTIVE: To evaluate the effects of intra-abdominal surgical emergency on breathing pattern and gas exchange and compare it with the changes induced by elective abdominal surgery. DESIGN: Prospective clinical study. SETTING: Abdominal surgical departments in a university hospital. PATIENTS: Patients operated for intra-abdominal emergency (n = 10, EAS), elective upper abdominal (n = 19, UAS). MEASUREMENTS AND RESULTS: Breathing pattern and gas exchange were measured with a respiratory inductive plethysmograph and a gas exchange monitor. EAS patients had pre-operatively a classical rapid shallow breathing pattern and increased ventilatory demand due to increased energy expenditure. The operation improved the breathing to normal pattern (frequency, 26 +/- 5/min and 17 +/- 3/min, p < 0.01; tidal volume, 439 +/- 128 ml and 541 +/- 165 ml, NS., before and after surgery, respectively). Sighing was absent before and after EAS and strictly reduced after elective surgery (p < 0.01 for UAS). The operation restricted the abdominal-diaphragmatic breathing movement which was reflected as increased contribution of the rib cage to VT (%RC: from 37% +/- 15 to 57% +/- 15 for UAS p < 0.001; from 47% +/- 16 to 61% +/- 14 for EAS NS.). After EAS and UAS hypoxemia was common (p < 0.001) with frequent radiological pathology. We conclude that intra-abdominal surgical emergencies increase the ventilatory demand and challenge the respiratory system to marked adaptive changes both pre- and post-operatively.

Propofol-nitrous oxide versus thiopentone-isoflurane-nitrous oxide anaesthesia for uvulopalatopharyngoplasty in patients with sleep apnea.

A randomized prospective study was performed to compare the recovery in 41 patients undergoing uvulopalatopharyngoplasty (UPPP) with either propofol-nitrous oxide-fentanyl or thiopentone-isoflurane-nitrous oxide-fentanyl anaesthesia. The patients were referred to UPPP after examination including polysomnography and otorhinolaryngological examination. The propofol group received propofol 2 mg.kg-1 for induction followed by an infusion of 10 mg.kg-1.h-1 after intubation. The thiopentone-isoflurane group received 5 mg.kg-1 of thiopentone for induction followed by isoflurane (0.5-2%) after intubation. Other medication was similar in both groups. In the propofol group the patients had a significantly better oxygen saturation during the first postoperative hour (P < 0.05), and a higher rate of breathing (P < 0.05), indicating a more rapid recovery of the physiologic control of breathing. Pain as measured by visual analogue score was lower (P < 0.05) during the second postoperative hour compared with the isoflurane group. Apneic episodes occurred with similar frequency in both groups, and they were related to the severity of obstructive sleep apnea (OSA). We conclude that propofol is preferable to thiopentone-isoflurane in UPPP operations, because physiologic respiratory control recovers faster and postoperative pain is less intense.

Ibuprofen in the treatment of postoperative pain in small children. A randomized double-blind-placebo controlled parallel group study.

The efficacy of ibuprofen as a pre-emptive analgesic for postoperative pain was investigated in 81 children in the age between one and four years subjected to elective surgery. The patients were randomized into two groups receiving rectally either ibuprofen 40 mg.kg-1.d-1, divided into four equal doses, or placebo in a double blind manner. Additional pain relief was provided by morphine. In the recovery room ibuprofen provided superior pain relief during the first hour and significantly reduced the need of morphine. Heart rate and arterial blood pressure were lower in children who received ibuprofen, probably reflecting better analgesia. The side effects were mild and similar in both groups. We conclude that rectal ibuprofen is a safe analgesic in children in the age between 1 and 4 years and reduces the need of opioids for postoperative pain relief.

Effect of single-dose omeprazole and ranitidine on gastric juice acidity and volume in patients undergoing laparotomy.

The effects of oral omeprazole and oral ranitidine on gastric fluid volume and pH were compared in 95 elective surgical patients, randomly assigned to one of three groups. The patients received either 80 mg of omeprazole or 300 mg of ranitidine orally at 6.00 on the morning of surgery. One third of the patients received no antacid therapy. Following induction, a no. 18 nasogastric tube was passed into the stomach and all available gastric fluid was aspirated. pH and volumes were measured. In the omeprazole- and ranitidine-treated groups, the mean pH was > 5.4 after induction, at completion of surgery and 1 h after operation, although at least one patient in both groups had pH < 2.5. The volumes of gastric aspirates were reduced equally by both drugs. Two patients in the omeprazole group, none in the ranitidine group and eight in the control group (26%) had pH < 2.5 with volume > 25 ml at induction. Both drugs appeared to be effective in reducing the volume of intragastric fluid and acidity to acceptable values.

Effect of dihydroergotamine on leg blood flow during combined epidural and general anaesthesia and postoperative deep vein thrombosis after cholecystectomy.

The effects of dihydroergotamine (DHE) on the circulation of the leg during combined epidural and general anaesthesia were studied to determine if DHE would enhance leg blood flow and prevent postoperative deep vein thrombosis in a double-blind trial of 40 elderly female patients subjected to cholecystectomy. Central and big toe temperature, arterial blood pressure, heart rate, calf volume and arterial inflow of the leg by electrical impedance plethysmography and the venous outflow by Doppler method were measured. DHE 0.5 mg subcutaneously reduced the volume of the leg, i.e. increased the electrical impedance, probably due to venous vasoconstriction. Simultaneously the need for etilefrine hydrochloride was reduced. No significant changes in the pulsatile inflow of the leg or the outflow were detected. Deep vein thrombosis (DVT) was detected by fibrinogen uptake test in five patients (three in DHEH and two in the control group) and verified by ascending phlebography in four patients. Intraoperative characteristics in patients with postoperative DVT were tachycardia (P < 0.001), enhanced need for etilefrine (P < 0.01) and a more rapid increase in big toe temperature (P < 0.05) after induction of epidural analgesia, compared with patients without DVT. Femoral vein flow velocity remained at the preinduction level, whereas pulsatile arterial inflow slightly increased. Together with a low basal impendance of the leg, the changes were indicative of a more intense vasodilatation, probably leading to stagnant flow and development of postoperative deep vein thrombosis.

[Pediatric surgery. A comparison of spinal anesthesia and general anesthesia]. / Operationen im Vorschulalter. Vergleich von Spinalanästhesie und Allgemeinanästhesie.

Forty patients aged 2 to 5 years who were admitted for paediatric operations were randomly assigned to have either spinal or general anaesthesia. Spinal anaesthesia was achieved with isobaric bupivacaine 0.5% at a dose of 0.5 mg/kg. General anaesthesia was induced with thiopentone 2-5 mg/kg and continued with low-dose fentanyl (1-2 micrograms/kg, oxygen/nitrous oxide/isoflurane (30/70/0.1-0.5%), vecuronium normoventilating the patients. The time spent in the operation room was shorter in the spinal anaesthesia group because the children were awake and could immediately be transferred. The haemodynamic pattern and respiratory function were stable during spinal anaesthesia. After general anaesthesia, respiratory function deteriorated as indicated by arterial desaturation (< 90%), which was detected in 11 of the 20 patients after general anaesthesia. Vomiting (2), sore throat (4) and micturition difficulties (2) were the adverse events associated with general anaesthesia. Three patients were restless after spinal anaesthesia. It can be concluded that spinal anaesthesia is a suitable anaesthetic technique for paediatric surgery.