The lack of analgesic efficacy limits tramadol as a sole agent to treat severe pain after surgery. However, it has a relative lack of respiratory depressant and constipating effects compared with morphine and codeine, and does not share the propensity of nonsteroidal anti-inflammatory drugs to provoke asthma, gastrointestinal mucosal damage and renal impairment. It may well have a place in the management of pain after surgery, in combination with another drug, such as paracetamol, or after control of the worst of pain after surgery by a regional local anaesthetic technique.

Opioids were available in clinical practice since before the birth of modern anaesthesia--Setürner isolated morphine in 1806. They have a record of safety which is reflected in their high therapeutic ratios, especially the synthetic opioids introduced recently (table III). The most serious immediate adverse effect, respiratory depression, is a predictable effect related closely to analgesia. It is fortunate for anaesthetists who use opioids regularly, that recognition and treatment of respiratory problems are an integral part of their craft and that opioid antagonists are effective in reversing respiratory depression.

Background-Guidelines on patient selection for lung cancer resection identify a predicted postoperative forced expiratory volume in 1 second (ppoFEV 1 ) of <40% as a predictor of high risk. Experience with lung volume reduction surgery suggests that ppoFEV 1 may be underestimated in those with concomitant emphysema. Methods-Anatomical lobectomy was performed in 29 patients with a resectable lung cancer within a poorly perfused, hyperinflated emphysematous lobe identified by radionuclide perfusion scintigraphy and computed tomographic scanning. Perioperative changes in spirometric parameters at 3 months were compared in 14 patients (group A) of mean age 69 years (range 48-78) with ppoFEV 1 <40% (mean (SD) 31.4 (7)%) and 15 patients (group B) with ppoFEV 1 >40% (mean (SD) 47 (5)%). The correlation between predicted and actual postoperative FEV 1 was also assessed. Results-In group B there was a significant perioperative reduction in FEV 1 (p=0.01) but in group A FEV 1 did not change significantly after lobectomy (p=0.87); mean diVerence in perioperative change between groups A and B 331 ml (95% CI 150 to 510). Despite the diVerence in ppoFEV 1 between the groups, there was no diVerence in actual FEV 1 at 3 months. In-hospital mortality was 14% in group A and zero in group B, but at a median follow up of 12 (range 6-40) months there was no diVerence in survival between the groups. Conclusions-Selection for lung cancer resection in patients with emphysema using standard calculations of ppoFEV 1 may be misleading. The eVect of lobar volume reduction allows for an extension of the selection criteria. (Thorax 2001;56:791-795) Keywords: lobar volume reduction surgery; lung cancer; patient selectionIncreasing the resection rate is fundamental to improving outcome in non-small cell lung cancer (NSCLC). The suboptimal resection rate in the UK, currently around 10%, 1 2 may be partly attributed to the assessment of inoperability in the large number of patients who have both lung cancer and concomitant emphysema. Prediction of postoperative respiratory function has been found to be a predictor of pulmonary complications, 4 with a predicted postoperative forced expiratory volume in 1 second (ppoFEV 1 ) measurement of less than 40% predicted associated with an unacceptable risk of postoperative morbidity.5 These values have previously guided our patient selection. However, increased understanding of lung volume reduction surgery (LVRS) has shown that resection of relatively functionless emphysematous lung may actually improve lung function. We have therefore applied the principles of selection for LVRS to those patients presenting with resectable NSCLC and moderate to severe emphysema. We report our initial experience with this cohort of patients undergoing lobectomy for NSCLC who, as a result, eVectively have undergone LVRS. Our objectives were to assess whether lung function changes uniformly with lobectomy in all patients, whether the currently used predictive methods are accurate in all cases, and whether the cu...

The effects of a single bolus dose of etomidate 0.3 mg kg-1 or thiopentone 5 mg kg-1, on the synthesis of corticosteroid hormones and adrenocorticotrophic hormone (ACTH), were compared for 24 h in 12 patients, undergoing minor surgery under general anaesthesia. Following opioid premedication i.m. and general anaesthesia, plasma cortisol concentrations decreased transiently within the first hour of anaesthesia in all 12 patients. The six patients who received etomidate had statistically higher plasma 11-deoxycorticosterone concentrations at 4 and 24 h than those who had received thiopentone (P less than 0.01). Throughout the study, no difference in plasma cortisol, corticosterone or ACTH concentrations were found between the two groups. We have demonstrated a biochemical effect of a single bolus dose of etomidate consistent with incomplete inhibition of adrenocortical mitochondrial 11 beta-hydroxylase activity, but no clinically significant adrenocortical suppression.