Exaggerated cardiovascular response to anaesthesia--a case for investigation.

We present a case of a 40-year-old woman who developed major cardiovascular complications during anaesthesia for an elective clipping of a cerebral arteriovenous malformation. Postoperative investigation confirmed the diagnosis of an adrenal phaeochromocytoma. In retrospect, it became apparent that she had experienced a series of potentially life-threatening events over a 20-year period all of which are known complications of phaeochromocytoma. This case highlights the importance of investigating young patients who have unexpected and unexplained cardiovascular events during anaesthesia and surgery.

Propofol and electroconvulsive therapy in a patient at risk from acute intermittent porphyria.

A severely depressed 57-yr-old woman at risk from acute intermittent porphyria presented for a course of electroconvulsive therapy. With propofol as the induction agent the course of electroconvulsive therapy was both uneventful and successful.

Patient satisfaction with general anaesthesia. Too difficult to measure?

A questionnaire to evaluate patient satisfaction following general anaesthesia was designed with the aid of focus groups. A subsequent audit identified aspects of care which could be improved on the basis of responses to the satisfaction questionnaire. It is possible to design a discriminating satisfaction questionnaire for general anaesthesia.

Comparison of conventional Lewis-Tanner two-stage oesophagectomy with the synchronous two-team approach.

Twenty-seven patients with oesophageal carcinoma had subtotal oesophagectomy by the Lewis-Tanner operation (group 1, n = 14) or a synchronous modification (group 2, n = 13). Synchronous operations were completed more quickly (230 versus 305 min, P < 0.01), but with more time spent under single-lung anaesthesia (160 versus 120 min, P < 0.01) and a greater fall in systolic blood pressure during hiatal manipulation (60 versus 30 mmHg, P < 0.01). Operative blood loss was not significantly greater in group 2, but the total volume of blood transfused in the peri-operative period was greater in this group (5 versus 3 units, P < 0.01). Four patients in group 1 suffered significant postoperative complications, compared with seven in group 2; three postoperative deaths occurred in group 2. This study suggests that the synchronous two-team oesophagectomy produces a higher incidence of complications than the conventional operation. Continued use of the Lewis-Tanner two-stage oesophagectomy is recommended for patients with carcinoma of the oesophagus.

Comparison of conventional Lewis-Tanner two-stage oesophagectomy with the synchronous two-team approach.

Twenty-seven patients with oesophageal carcinoma had subtotal oesophagectomy by the Lewis-Tanner operation (group 1, n = 14) or a synchronous modification (group 2, n = 13). Synchronous operations were completed more quickly (230 versus 305 min, P < 0.01), but with more time spent under single-lung anaesthesia (160 versus 120 min, P < 0.01) and a greater fall in systolic blood pressure during hiatal manipulation (60 versus 30 mmHg, P < 0.01). Operative blood loss was not significantly greater in group 2, but the total volume of blood transfused in the perioperative period was greater in this group (5 versus 3 units, P < 0.01). Four patients in group 1 suffered significant postoperative complications, compared with seven in group 2; three postoperative deaths occurred in group 2. This study suggests that the synchronous two-team oesophagectomy produces a higher incidence of complications than the conventional operation. Continued use of the Lewis-Tanner two-stage oesophagectomy is recommended for patients with carcinoma of the oesophagus.

Anaesthesia for patients with transplanted hearts and lungs undergoing non-cardiac surgery.

Heart and lung transplantation is now accepted as a means of treating some end-stage cardiopulmonary diseases. These patients may present with a wide variety of non-cardiopulmonary conditions requiring anaesthesia and surgery, possibly at a place distant from their original transplant centre. In general, for much elective, acute or even emergency surgery, if the allograft is functioning satisfactorily, these patients should present few problems during anaesthesia, provided the anaesthetist has some understanding of the pathophysiology of the transplanted organ and recognizes the differences (potential and specific to cardiopulmonary transplantation) between such patients and any other subject.

Liposome-incorporated corticosteroids: I. The interaction of liposomal cortisol palmitate with inflammatory synovial membrane.

Cortisol palmitate-containing liposomes were stable in rheumatoid synovial fluid at 37 degrees. Two hours after the intra-articular injection of such liposomes into experimentally arthritic rabbits relatively high proportions of the steroid and lecithin components were recovered from the synovialis. The level of cortisol in the tissue at this time was inversely related to the chronicity of the inflammation. It was found also that the degree and duration of the anti-inflammatory activity of the liposomes was greatest in the initial acute phases of the inflammation.

Liposomal retention of a modified anti-inflammatory steroid.

In studies with synthetic lecithins, dipalmitoylphosphatidylcholine was found to be the preferred form for liposomal retention of cortisol esters at 37 degrees C. Cortisol palmitate was retained longer than cortisol octanoate, whereas unesterified cortisol escaped readily from liposomes. Such a liposome composition may allow the controlled release of modified anti-inflammatory agents, particularly when used for intra-articular administration.

The Arthus reaction in guinea-pig knee joints. A test for anti-inflammatory drugs.

A reversed passive Arthus reaction was produced in guinea-pig knee joints by intravenous injection of ovalbumin and intra-articular injection of homologous anti-ovalbumin antiserum or specific IgG2 antibody. The optimum response was obtained by varying the concentration of antigen while keeping the amount of antibody constant. Joint swelling, leucocyte infiltration in the synovial fluid and joint pathology were measured 4-6 hours and 24 hours after initiation of the reaction. The RPA lesions were almost completely inhibited by complement or polymorphonuclear leucocyte depletion. The effects of a range of drugs on the 4-6 hours response were investigated following intraperitoneal or oral administration. Cyproheptadine hydrochloride, Trasylol, indomethacin, aspirin, phenylbutazone, prednisolone sodium phosphate, chloroquine diphosphate, SKF36914 (gold triethyl phosphine), cyclophosphamide, ketoprofen, sudoxicam and naproxen all reduced one or more of the symptoms of inflammation. However, cyproheptadine was only active at high and probably non-specific dose levels. D(-)penicillamine hydrochloride and mepyramine maleate were inactive.