Summary The present study tested the hypothesis that patients receiving epidural bupivacaine before surgery would require less morphine postoperatively and/ or report less intense pain than patients receiving epidural bupivacaine after incision but before the end of surgery. Forty-nro patients (ASA class I-III) scheduled for lower abdominal surgery were randomly assigned to I of 2 groups of equal size and prospectively studied using a double-blind, placebo-controlled crossover design. Epidural catheters were placed in the Tlz-Ll or L1-L2 interspaces pre-operatively, the position of the catheter was confirmed with 3Vo chloroprocaine with epinephrine L :200,000, and sensory testing was carried out until levels had receded to below T12. Group I received 15 ml of 0.5Vo epidural bupivacaine injected 35 min before incision followed by 15 ml of epidural normal saline 30 min after incision. Group 2 received 15 ml of epidural normal saline injected 37 min before incision followed by 15 The results suggest that single-shot pre-emptive epidural local anaesthesia is associated with a short-term morphine-sparing effect which is most pronounced between 12 and 24 h after surgery. Extending the pre-operative blockade into the postoperative period may prolong the initial advantage conferred by pre-emptive epidural local anaesthesia.

Summary This study tested the hypothesis that high dose systemic alfentanil administered before and during aMominal hysterectomy would pre-empt post'operative pain to a greater extent than administration of either low dose alfentanil or no alfentanil perioperatively. Patients (ASA I or 2) were randomly assigned to group 1 (r = 15), no opioid; group 2 (n = 15), low dose alfentanil; or group 3 (n = l5). high dose alfentanil. Anaesthesia was induced in group I with midazolam and thiopentone and was maintained with isoflurane andTO% N2O in 02, Anaesthesia was induced in group 2 with midazolam, thiopentone and i.v. alfentanil (30pg kg-l), and was maintained with isoflurane. 70VoN2O in 02, and bolus doses of i.v. alfentanil (10-20pg kg-l) every hour. Anaesthesia was induced in group 3 withmidazolamandi.v. alfentanl (l0opgkg-t),and wasmaintained wtlt70% N2Oin Oz,andanintusionof i.v. alfentanil(l-2pgkg-l min-l). Blood samples were drawn at 30 and 120 min after surgery and assayed for plasma alfentanil. Morphine consumption and VAS pain scores were consistently lowest in group 3 over the 48 h study period, A composite measure of pain and morphine consumption was significantly lower in group 3 than group 2 up to 6 h after surgery and significantly lower than group I up to 12 h. No adverse effects were observed. A 6-month follow-up did not reveal any significant differences among the three groups. It is concluded that intra-operative high dose alfentanil anaesthetic pre-empts post-oporative pain after abdominal hysterectomy, but the effects are small and of short duration.Surgical procedures carried out under general anaesthesia using standard (and even high) doses of opioids intraoperatively provide suboptimal protection from the injury banage brought about by incision and subsequent noxious surgical events.

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An 80 year old female presented with the clinical featmes of a perforated intra-abdominal viscus. Following rapid sequence of anaesthesia the larynx was visualised but an endotracheal tube could not be passed below the level of the cricoid. The registrar called the consultant__ and proceeded to manually ventilate the patient with 1 0(Oo o~(ygen via the face mask. Gross subcutaneous emphysema of the neckand upper trunk then developed and the patient became cyanose& Despite the inconclusive chest X-ray bilateral chest drains were inserted. The patient resumed spontaneous respiration and her condition improved.Following re-inroduction of anaesthesia a 6.0 endotracheal tube was passed. Bronchoscopy and laryngoscopy revealed no evidence of trauma. There was no difficulty with ventilation via the tube anaesthesia being maintained with oxygen, nitrous oxide, enflurane and pancuronium. Subcutaneous emphysema increased initially after intubation, thereafter anaesthesia proceeded uneventfully and laparotomy revealed alarge hiatus and perforation of the intrathoracic stomach.

Correspondence Priapism and general anaesthesiaRecently the urology journals have shown interest in the medical management of priapism. Successful agents are alpha adrenoceptor agonists, for example metaraminol (1 mg), ephedrine (50 pg), phenylephrine, or dopamine, injected into the corpus cavernosum.'--'We had a case of priapism under general anaesthesia that prevented the urologist from passing the cystoscope. Ten milligrams metaraminol was injected into the corpus by the surgeon. This solved the problem, and the operation was over in 5 minutes. However, the patient developed ventricular tachycardia, that approached a rate of 200 beats/ minute, with an arterial blood pressure of 200/140 mmHg. This settled without treatment and the patient made a full recovery.Two deaths have been reported from the use of metaraminol to treat priapism; both were attributed to arterial hypertension. The development of ventricular tachycardia was potentially serious in this case; the dose was about 10 times that recommended.