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SummaryIn a double-blind, randomised trial, we compared the effects of pretreatment with midazolam at two different doses (0.025 and 0.05 mg.kg 21 ), with placebo, on the induction dose requirements of propofol in two different age groups. We enrolled 120 patients: 60 younger patients (aged 18± 35 years) and 60 older patients (aged over 60 years). All patients received 0.75 m g.kg 21 of fentanyl, plus a blinded pretreatment with either saline or one of two doses of midazolam. Induction continued with a fixed rate infusion of propofol. Propofol dose requirement was recorded, as were cardiovascular parameters and the occurrence of significant apnoea (. 60 s). Midazolam pretreatment was associated with a significant reduction in propofol dose requirement in both younger and older patients. The reduction in older patients was significantly greater than the equivalent response in younger groups. There was no demonstrable benefit in terms of improved cardiovascular stability or reduction in the incidence of apnoea. Caution is advised in the use of midazolam as an agent for co-induction with propofol in the elderly.

Morbid obesity is associated with a reduction in time to desaturate during apnoea following standard pre-oxygenation and induction of anaesthesia. We have compared the effects of using 7.5 cmH2O of continuous positive airway pressure (CPAP) for pre-oxygenation with a standard technique using a Mapleson A breathing system, in 20 morbidly obese women. In a prospective, open, randomised trial, we measured the time taken to desaturate to 90% from time of giving a succinylcholine bolus as part of a rapid induction of anaesthesia. All patients received 3 min pre-oxygenation prior to induction. Tracheal intubation was confirmed and all patients kept apnoeic until oxygen saturation decreased to 90%. No statistically significant difference in mean time to desaturate to 90% could be demonstrated in the CPAP group compared to the Mapleson A group (240 s and 203 s, respectively). A brief period of lower mean heart rate in the CPAP group was the only statistically significant difference in cardiovascular parameters. There was no significant difference in the volume of gastric gas after induction between groups.

Summary Drotrecogin alfa has been shown to reduce mortality in severe sepsis. However, it remains unlicensed for use in patients with previous liver transplantation. We report its use in such a case. Prior to administration a risk benefit analysis was performed in line with General Medical Council recommendations. This included being satisfied that no appropriately licensed alternative would better serve the patient's needs and that sufficient evidence existed to demonstrate the safety and efficacy of the drug. Responsibility was taken for prescription, monitoring and follow up. The process was carefully documented and the patient recovered fully with no adverse effects. To date the only published data on the use of drotrecogin alpha in transplant recipients is a case series of three patients. Further published data may encourage review of the licence.

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