Summary We studied the effect of the addition of hyaluronidase to a mixture of lignocaine 2% and bupivacaine 0.75% for peribulbar anaesthesia in 60 patients presenting for elective intra‐ocular surgery. Using a randomised, double‐blind design, patients were allocated to one of three groups: no hyaluronidase (group A) (n = 20); hyaluronidase 50 iu.ml‐1 (group B) (n = 20); hyaluronidase 150 iu.ml‐1 (group C) (n = 20). The speed of onset of the block, the presence of akinesia, analgesia and the need for supplementary injections were assessed. The addition of 150 iu.ml‐1 of hyaluronidase resulted in a mean (SEM) time to akinesia of 9.2 (0.9) min compared to 10.9 (0.9) min in the control group and 10.7 (1.1) min in those receiving the lower dose. Fewer patients in group C required a further injection (20%) than those in groups A (40%) or B (45%). None of the findings were statistically significant. Hyaluronidase was not associated with any complications.

SummaryPain relief after surgery is. frequently inadequate. In the last few years much research has been devoted to improving the situation. Unfortunately, very little work has been undertaken to explore the patients' contribution to pain management. The beliefs and attitudes held by patients when they enter the hospital environment may be responsible in some instances for their not achieving optimal pain relief from the available techniques. We have studied some of these attitudes with a survey of 180 adult patients admitted for elective surgery. We found that most patients still expect pain. following surgery. However, they are not afraid to ask for analgesics when in pain and do not attribute pain to their own wrong doing. There are, however, some patients who appear to have deviant’ pain beliefs that could hinder their appropriate use of analgesics. Sadly, it is impossible to identify these patients according to age, gender, socio‐economic group or previous experience of pain or surgery.

Summary

A prospective, randomized, double-blind study was performed to investigate whether altering the rate of injection of local anaesthetic through a Whitacre needle had any effect on the spinal block achieved. Twenty patients scheduled for elective urological surgery under spinal anaesthesia received an injection of 3 ml of 0.5% plain bupivacaine either by hand (fast) over 10 s (18 ml min(-1)) or by infusion pump (slow) over 3 min (1 ml min(-1)). All patients were in the sitting position both during insertion of the spinal needle and for 3 min after the start of spinal injection, and they then changed to the supine position. The slow injection group achieved peak sensory block earlier, after a median interval of 20 (95% confidence interval 12.5-30) min vs 30 (22.5-45) min (P<0.05) for the fast group. The level of peak sensory block was similar: T3.5 (T2-T4.5) vs T4 (T1.5-T6.5). The time to lowest mean arterial pressure occurred earlier in the slow group, at 10 (8 to 18) vs 20 (15-31) min (P<0.05). Duration of the motor block was shorter in the slow group: 180 (152-242) vs 270 (225-300). We conclude that a slow spinal injection of plain bupivacaine results in a block of more rapid onset and recovery.

The American College of Surgeons' Advanced Trauma Life Support procedure teaches that blind nasotracheal intubation should be performed in the presence of a suspected or proven cervical spine injury in an unconscious but breathing patient who requires an artificial airway. We studied a group of non-anaesthetically trained graduates of the Advanced Trauma Life Support course and examined their skill in performing blind nasal intubations. Only six in 90 attempts were successful. We conclude that, in British hospitals, blind nasotracheal intubation should not be recommended as the first line management in securing the airway of patients with suspected or proven cervical spine injury. Alternative techniques such as bag-and-mask ventilation with cricoid pressure or a laryngeal mask airway with cricoid pressure should be adopted until oral intubation with in-line traction is performed.