Efficacy and kinetics of extradural ropivacaine: comparison with bupivacaine.

Ninety-one patients were allocated randomly to three groups to receive 1% ropivacaine 10 ml, 0.5% ropivacaine 20 ml or 0.5% bupivacaine 20 ml extradurally. Intermittent sensory (pinprick) and motor (Bromage scale) assessments of the block produced were recorded, with an assessment of the quality of the block and the requirement for supplementary analgesia. There was little difference between the groups in frequency, onset, duration or spread of sensory block. However, the motor block produced by 0.5% ropivacaine was less intense and of shorter duration than that with bupivacaine. The block produced by the smaller volume of ropivacaine was less reliable clinically than the larger, more dilute, solution and more anaesthetic supplements were required in that group. Cardiovascular changes were similar in all three groups. The peak plasma concentration of ropivacaine was significantly greater and T1/2 significantly shorter than those of bupivacaine, although no patient showed any features of systemic toxicity. The systemic kinetics of ropivacaine were not influenced significantly by varying the concentration or volume administered.

Interleukin-8 and development of adult respiratory distress syndrome in at-risk patient groups.

Neutrophils have been implicated in the pathogenesis of the adult respiratory distress syndrome (ARDS). We have measured concentrations of the neutrophil attractant interleukin-8 in blood and bronchoalveolar lavage fluid (BAL) from patients at risk of ARDS. We studied 29 patients from three groups at risk of developing ARDS: multiple trauma (n = 16), perforated bowel (n = 6), and pancreatitis (n = 7). ARDS developed in 7 of these patients. Interleukin-8 in BAL and blood samples taken on initial hospital presentation was measured by a sandwich enzyme-linked immunosorbent assay. The mean BAL interleukin-8 concentration was significantly higher for the patients who subsequently progressed to ARDS than for the non-ARDS group (3.06 [SE 2.64] vs 0.053 [0.010] ng/mL, p = 0.0006). There was no difference between the groups in plasma interleukin-8 (6.23 [2.60] vs 5.12 [2.22] ng/mL, p = 0.31). Immunocytochemistry suggested that the alveolar macrophage is an important source of interleukin-8 at this early stage in ARDS development. This study provides evidence of a relation between the presence of interleukin-8 in early BAL samples and the development of ARDS. The early appearance of interleukin-8 in BAL of patients at risk of ARDS may be an important prognostic indicator for the development of the disorder and reinforces the likely importance of neutrophils and the effects of their accumulation and activation in the pathogenesis of many cases of ARDS.

Paediatric trauma in northern Iraq: the Kurdish refugee crisis.

In May 1991 a team of five doctors and two nurses from Edinburgh hospitals were flown to Northern Iraq to assist in the Kurdish refugee relief effort. The two surgical members of the team helped to re-establish surgical services in a small hospital in the Iraqi town of Zakho. During an 8-day stay in the hospital, frequently in extremely difficult circumstances, the surgical team undertook 19 major and 15 minor surgical procedures in 25 patients; 11 major and eight minor procedures were undertaken in 15 children under the age of 16 years. The largest group of children treated had suffered bomb-blast injuries from unexploded ordinance; injuries sustained were primarily to the hands, face and upper trunk. Road traffic accidents and burns were also common. Two children requiring postoperative intensive care were evacuated by military helicopter at night to hospital facilities in Turkey.

Advanced airway control in trauma resuscitation.

Definitive airway control which may require endotracheal intubation with or without an induction agent and muscle relaxant is an essential component of trauma resuscitation. We reviewed the delivery of advanced airway care in the resuscitation room of a regional trauma centre. This prospective survey suggests that in the absence of an experienced anaesthetist, A&E staff with a background of suitable training and experience may undertake the anaesthetic responsibility associated with securing a definitive airway when the situation demands.

Alveolar macrophage chemotaxis in fire victims with smoke inhalation and burns injury.

In vitro migration of alveolar macrophages was studied in 24 fire victims and 19 controls; all subjects were cigarette smokers. Unstimulated (P = 0.01) and stimulated migration towards casein-(P = 0.01) and zymosan-activated serum (P = 0.002) of macrophages from smoke inhalation patients (SI) (n = 19) was increased when compared to control subjects (CS). Migration of alveolar macrophages from patients with burns without smoke inhalation (burns only, BO) was not increased. Patients with smoke inhalation and no burns (smoke only, SO) (n = 9) had increased migration when compared to controls but this was not statistically significant. Patients with smoke inhalation and burns (SB) (n = 10) had increased unstimulated migration (P = 0.01) and increased migration towards casein (P less than 0.005), ZAS (P less than 0.002) and F-met-leu-phe (P less than 0.05) when compared to controls (CS). Lavage fluid from the fire victims displayed chemotactic activity towards normal human neutrophils and its analysis for the components of the complement cascade proved positive (Clq, Clr, Factor B and C3). These data suggest that activation of alveolar macrophages may contribute to the development of pathophysiological changes in patients with smoke inhalation (SI) and particularly those with smoke inhalation and burns (SB).