The use of extradural analgesia to avoid straining in a primigravida with portal hypertension and secondary oesophageal varices is described, together with a discussion of the advantages and disadvantages of this approach.

SummaryA patient with the Eisenmenger syndrome presented for removal of a carotid body tumour under general anaesthesia. The presentation and management of the case are described and some of the anaesthetic problems associated with these I W O uncommon conditions are discussed. The case is reported because of its rarity and because some of the complications of carotid body surgery may be particularly hazardous in the presence of the Eisenmenger syndrome. The importance of monitoring, of maintaining a stable heart rate and blood volume, and the danger of paradoxical systemic air embolism are stressed.

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Buprenorphine 0.6 mg and syntocin 20 units were administered after delivery and the nitrous oxide concentration was increased to 70%. The enflurane was stopped 30 min after delivery and 30 min before the end of the procedure. The pulse was 85 to I00 per minute and the arterial blood pressure was I3& 145/65-80 mmHg.Halfway through skin closure, havingobservedefforts at spontaneous ventilation, I decided to switch off the ventilator and let the patient breathe herself. This was 45 minutes after the last dose of relaxant. On the switchover the patient's heart rate suddenly fell from 82 to 40 beats per min; sinus rhythm was maintained. The sinus bradycardia persisted for 2 min and therefore atropine (0.6 mg) was administered. This was followed by an increase in heart rate to 104 and blood pressure wasrecordedas 172/10OmmHg.Thepatient maintained good ventilation during this time, and awoke shortly after the nitrous oxide was stopped.The abruptness of the change in heart rate, which coincided with a change in mode of ventilation, led me to believe that the two were linked. It is possible that this phenomenon was observed because of the absence of cardiovascular effects of atracurium and because no drugs with autonomic effects had been used. My impression was that continued mechanical ventilation while the patient was starting to make efforts out-of-phase with the ventilator had increased the intrathoracic pressure which was similar to a prolonged Valsalva manoeuvre. Blood pressure was not measured during the bradycardia but the patient was hypertensive immediately after the administration of atropine.It would be interesting to know whether a similar episode hasbeen observed before, particularly in association with atracurium. Department of Epidural analgesia: a valuable precautionIt is always recommended that equipment should be checked before continuous epidural analgesia is started. Epidural cannulae have been known to be supplied kinked or without lumens.' Epidural analgesia was recently to be used in this hospital for labour pain in a parturient. A bacterial filter was connected to the epidural cannula (Everett-Hinders Leslies Ltd) and an attempt made to fill the whole system with normal saline in our routine manner. Total resistance was met and we were unable to inject the saline. The cannula was disconnected from the filter and it was easy to flush the latter with saline. A blocked or eyeless cannula was considered. Another cannula was requested; this was a Portex Ltd cannula and the fitting was removed. The needle was disconnected from the first cannula and connected to the second. We were again unable to flush the system. The needle was detached from the second cannula and it was tested separately. It was impossible to inject saline through this needle. Epidural analgesia was established using the Portex cannula with its fitting and was uneventful.Later inspection of the needle revealed that there was no hole in the hub of the needle.Direct questioning of seven junior anaesthetists (Senior house officers and ...

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