Anaesthesia and breast-feeding--the effect on mother and infant.

In this paper, we summarise the physiology of lactation and discuss the pathophysiology brought about by fasting, stress and anaesthetic drugs. Drug secretion into breast milk and subsequent absorption by the infant is considered. Maternal hydration must be well maintained with intravenous fluids, allowing an added 500 to 1000 ml for daily fluid loss in lactation. Maternal premedication, general anaesthesia and routine postoperative analgesics are also discussed as to the effects on the breast-fed infant. Drug side-effects may be avoided by timing breast feeding just before the next due dose. Sedatives with long half-lives should not be used. Endocrine and metabolic responses to anaesthesia and surgery are less with regional anaesthesia than with general, hence regional anaesthesia is preferred where it is a reasonable alternative technique.

Detecting lower motor neuron dysfunction of the pharynx and larynx with electromyography.

This study assessed the utility of clinical electromyography (EMG) for detecting lower motor neuron (LMN) or upper motor neuron (UMN) dysfunction affecting the intrinsic muscles of the larynx and pharynx. Twenty-nine subjects were examined; their clinical diagnoses included perioperative nerve injury, cerebral infarction, and lateral medullary infarction. Resting activity, motor unit action potential (MUAP) morphology, and MUAP recruitment were evaluated in every case. Medical records (excluding EMG data) were analyzed for clinical evidence of LMN or UMN dysfunction in the intrinsic muscles of the larynx and pharynx. The diagnosis of LMN dysfunction rested on clinical data consistent with cranial nerve injury, poliomyelitis, Wallenberg syndrome, or unilateral bulbar palsy. Criteria for UMN dysfunction included previous cerebral (not brainstem) infarction or mass lesion or the presence of hemiparesis. Electromyographic abnormalities were significantly associated with LMN dysfunction (p less than .05), but they were not significantly associated with UMN dysfunction. Of the parameters tested, MUAP recruitment was the most sensitive (82%) and specific (92%).

Pain relief for outpatient colonoscopy: a comparison of alfentanil with fentanyl.

Alfentanil was used as an adjuvant to midazolam for analgesia in thirty outpatients undergoing colonoscopy. A similar group of thirty outpatients received fentanyl. The operating conditions and recovery times of the two groups were compared. Alfentanil usage resulted in better operating conditions. Recovery time was similar. Patient acceptance was high. No patient suffered respiratory depression during or after the procedure.

Pharmacokinetics of alcuronium in elderly patients undergoing total hip replacement or aortic reconstructive surgery.

The pharmacokinetic behaviour of alcuronium was studied in three patients undergoing resection of an aortic aneurysm, and in another two patients undergoing total hip replacement (group I). A control group of five elderly patients undergoing relatively minor surgery was included (group II). In group I patients, the values of the pharmacokinetic parameters such as plasma clearance, elimination half-life and the apparent volume of distribution of the drug were found to be comparable to those obtained in normal young patients in previous studies. The group II patients, however, were found to have a prolonged elimination half-life as a result of reduced plasma clearance, possibly an age-related effect. The differences between these two groups of patients may be explained by the differences in the extent of haemorrhage and fluid replacement or changes in blood circulation, or both. However, alcuronium must still be used cautiously in both groups of patients, especially in the light of a recent finding that patients undergoing aortic reconstructive surgery have a high frequency of functional renal failure after operation.

Ciramadol--a new synthetic analgesic. A double-blind comparison with oral codeine for postoperative pain relief.

One hundred and eighty patients (American Society of Anesthesiologists rating 1-2) received one of three oral analgesics--ciramadol (Wy. 15705) 20 mg, ciramadol 60 mg or codeine 60 mg--on a double-blind random basis for the relief of pain 24-48 hours after major general surgical, gynaecological or orthopaedic operations. All three analgesics proved equally effective and caused mild sedation only. No patient showed signs of clinical cardiorespiratory depression, and other side-effects were infrequent. Ciramadol may therefore prove a useful clinical alternative to conventional oral analgesics provided its lack of respiratory depressant properties and addiction potential in monkeys can be substantiated in humans.

Midazolam for the intravenous induction of anaesthesia in children.

Midazolam was compared with thiopentone as an intravenous anaesthetic induction agent in children between four and twelve years of age undergoing elective minor surgical procedures. Successful induction of anaesthesia was achieved in both groups of patients. With midazolam induction time was longer than with thiopentone, but the difference was not statistically significant. The incidence of apnoea was greater with thiopentone, but not significantly so. It is concluded that midazolam is effective and safe, and could prove a reasonable alternative to thiopentone as an intravenous induction agent in children undergoing elective minor operations.

Midazolam, a new intravenous induction agent for anaesthesia.

In an open non-comparative clinical trial 64 patients older than 18 years with American Society of Anesthesiologists ratings of I and II were studied. Under standardized conditions of premedication, anaesthesia was induced by injecting midazolam (Ro 21-3981) 0,15 or 0,3 mg/kg body weight intravenously. After endotracheal intubation with suxamethonium 1 mg/kg, anaesthesia was maintained with nitrous oxide in oxygen and enflurane or halothane. There were statistically significant cardiovascular changes during and/or after intubation but there were no clinical consequences. Midazolam allows rapid induction of and recovery from anaesthesia. There was no retrograde amnesia and high proportion of the patients assessed the induction of anaesthesia as favourable. The local tolerance was very good. Midazolam seems to be a good alternative for induction of balanced anaesthesia.

Hyperbaric bupivacaine for spinal analgesia.

Sixty-one patients (ASA classification I-III) were studied in an open non-comparative trial to assess the efficacy of hyperbaric bupivacaine for spinal anaesthesia. In 59 patients the quality of analgesic block was good, while 2 required supplementary analgesia and sedation. Four patients became hypotensive, this requiring correction by fluid volume replacement. Hyperbaric bupivacaine, with a mean duration of action of 6 1/2 hours, has proved satisfactory in our anaesthetic practice.

An evaluation of the Hellige Transoxode (Servomed Oxymonitor SM 361 System): response to halothane and enflurane in vitro.

The effects of halothane (0.5-2%) and enflurane (1-4%) on two Transoxode transcutaneous oxygen (TcPO2) electrodes (Hellige Servomed Oxymonitor SM.361 system) were serially tested in atmospheres of nitrogen, air and 50% nitrous oxide in oxygen. Both TcPO2 electrodes reduced and "read" halothane but no enflurane. Calibration drift was significantly greater (p less than 0.05) after electrode exposure to halothane; 5.40 s.e.m. 1.37 kPa vs enflurane; -0.60 s.e.m. 0.93 kPa. Halothane has a direct effect in rendering the Transoxode inaccurate, which is probably clinically less important than the indirect cardiovascularly medicated influence of both halothane and enflurane on TcPO2 levels. A reduction in the electrode polarisation voltage is recommended to obviate the direct effect of halothane on Transoxode performance.

A performance evaluation of the Samson paediatric anaesthetic set.

The performance of the Samson paediatric set, used in Mapleson F mode, has been evaluated in 10 infants. It is a prepacked, sterile, disposable, light-weight and economical set, and would therefore seem to offer advantages over more conventional infant anaesthetic circuits. The oxygenation of patients was adequate throughout and the removal of carbon dioxide effective. No anaesthetic problems were encountered with this circuit. Postoperative chest infection did not occur in the 10 infants studied.

Flunitrazepam for the intravenous induction of anaesthesia in children.

Flunitrazepam (Rohypnol) was compared with thiopentone as an anaesthetic induction agent in children between 4 and 12 years of age who underwent elective minor surgical procedures. Successful induction of anaesthesia was achieved in both groups of patients. With flunitrazepam the induction time was longer but not statistically different from that with thiopentone. The incidence of apnoea was higher with thiopentone, but not significantly so. It is concluded that flunitrazepam could prove a reasonable alternative to thiopentone as an intravenous induction agent in children who have to undergo elective minor operations.

Bronchography in children aged 3 years and under. Anaesthetic techniques and results.

Bilateral bronchography was performed on 89 children aged between 3 months and 3 years. The bronchographic technique involves instillation of oily propyliodone into the tracheobronchial tree by positive pressure ventilation, and the procedure is carried out under general anaesthesia. Technically adequate bronchograms were obtained in 84 of the children, and with a solitary exception the complications of bronchography were few and trivial. In bronchiectatic children bronchography is a valuable and accurate investigation, which should in general be restricted to those patients who on clinical grounds are thought to have surgically manageable bronchiectasis.