We have tested the hypotheses that glycopyrrolate, administered immediately before induction of subarachnoid anaesthesia for elective Caesarean section, reduces the incidence and severity of nausea, with no adverse effects on neonatal Apgar scores, in a double-blind, randomized, controlled study. Fifty women received either glycopyrrolate 200 micrograms or saline (placebo) i.v. during fluid preload, before induction of spinal anaesthesia with 2.5 ml of 0.5% isobaric bupivacaine. Patients were questioned directly regarding nausea at 3-min intervals throughout operation and asked to report symptoms as they arose. The severity of nausea was assessed using a verbal scoring system and was treated with increments of i.v. ephedrine and fluids. Patients in the group pretreated with glycopyrrolate reported a reduction in the frequency (P = 0.02) and severity (P = 0.03) of nausea. Glycopyrrolate also reduced the severity of hypotension, as evidenced by reduced ephedrine requirements (P = 0.02). There were no differences in neonatal Apgar scores between groups.

Purpose: To quantify in vivo changes in miniscrew implant (MSI) stability over time using resonance frequency analysis, and to determine if pilot holes and placement sites affect changes in MSI stability. Materials and Methods: Twenty-two self-tapping MSIs (1.6 mm wide and 9 mm long) were placed in the maxillae of 2 adult beagle dogs (20 months old). The Osstell Mentor was used to measure the implant stability quotient (ISQ) weekly for 8 weeks. A split-mouth design was used to evaluate the effects of 1.1-mm wide, 3-mm deep pilot holes. Results: The MSIs that failed showed significantly (P , .05) greater decreases in ISQ values during the first 3 weeks than the MSIs that remained stable. All of the MSIs that failed (41%) had been placed in nonkeratinized tissue. MSIs that remained stable throughout the study also showed significant decreases in ISQ values during the first 3 weeks, followed by increases during the fourth and fifth weeks. Changes in ISQ values of MSIs inserted into bone with and without pilot holes were comparable (P . .05). Conclusion: Stability of unloaded MSIs decreased during the first 3 weeks and increased thereafter. Although the effects of pilot holes on stability could not be confirmed, placement of MSIs into nonkeratinized tissue negatively affected their stability and increased the likelihood of failures. (Angle Orthod. 2011;81:994-1000.)

SummaryWe observed practice during transfer of 80 patients from anaesthetic room to operating theatre, to determine the duration of apnoea and the time without monitoring during the transfer process. Median (IQR [range]) time from disconnection of the breathing system in the anaesthetic room to the first breath in theatre was 54 (44-65 [27-196]) s, and from disconnection of the pulse oximetry probe to the first reading in theatre was 90 (74-103 [44-182]) s. In four patients (5%) arterial oxygen saturation fell to 94%, with the greatest desaturation observed 11%. The transfer process may represent a window of opportunity for the occurrence of harm or the first step in a chain of events leading to harm, and is difficult to justify on patient safety grounds. In the United Kingdom it is common practice to anaesthetise patients in the anaesthetic room before transfer to the operating theatre. During transfer, patients tend to be neither monitored nor their lungs ventilated. This practice contrasts with other countries including the United States of America, Canada and Australia, where anaesthesia is routinely induced in the operating theatre. This issue has been discussed in the literature in general correspondence and editorials [1-3], but we are not aware of any studies measuring anaesthetic transfer times or adverse incidents relating to transfer. Our aims were to determine how long patients are unmonitored and apnoeic during transfer from the anaesthetic room to the operating theatre, and to record any adverse outcomes during this period. MethodsLocal Research Ethics Committee approval was obtained to observe routine staff practice during transfer of patients from anaesthetic room to operating theatre. We collected data for 80 cases, over a 4-month period. All cases were adult inpatients, of ASA physical status 1-3, undergoing induction of general anaesthesia in the anaesthetic room. After induction, patients were disconnected from monitoring and the breathing system, wheeled into theatre on a trolley, and transferred by slide to the operating table. Patients were followed from the anaesthetic room until fully monitored and their lungs ventilated in theatre. Principal measurements were the time from disconnection of the breathing system until the first breath in theatre, and the time from disconnection of the pulse oximetry probe until the first reading in theatre. We also noted the extent of pre-oxygenation (formal: ‡ 3 min via a tight fitting facemask or ‡ 4 vital capacity breaths; informal: any attempt at pre-oxygenation not fulfilling formal criteria; or none), whether the patient was on the trolley or the operating table when the first breath in theatre was given, and whether the patients' airways were managed using laryngeal mask airways or tracheal tubes. The theatre staff were unaware of the nature of the study. We asked permission to be present in the anaesthetic room and observe the beginning of each case and then leave, explaining that the nature of the study precluded revealing exactly what we were ob...

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We report the safe use of remifentanil as part of the anaesthetic technique in a patient undergoing major head and neck surgery who was being treated for depressive illness with the non-specific monoamine oxidase inhibitor (MAOI) phenelzine.

EditorÐThe use of opioids for non-cancer pain indeed remains a controversial subject. Simpson has given an excellent overview. 1 One particular area of concern is that there are few available data regarding the ef®cacy and safety of high dose opioids given over years rather than months. Whereas it was previously thought that unlimited dose escalation was at least safe, this dogma has recently been questioned. 2 Long-term use of opioids may be associated with the development of abnormal sensitivity to pain, 3 immunosuppression, and hormonal changes. I have found measurement of testosterone levels and replacement therapy to be an important consideration in male patients presenting with loss of libido in such circumstances. Patients with chronic pain may have symptoms that last 24 h a day, but short-acting opioids offer relief for only 3±4 h. For these patients, I generally recommend the use of long-acting opioids. Use of long-acting opioids may result in more predictable serum levels, less abuse, less reinforcement of drug-taking behaviours, and improved sleep, compared with short-acting opioids. The toxicity of acetaminophen is also avoided. 4 5

We found that a conservative approach to performing tracheostomy reduced the number of procedures performed without affecting overall unit outcomes.

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