SummaryNon-invasive positive pressure ventilation has previously been used successfully to treat both acute and chronic ventilatory failure secondary to a number of conditions, including scoliosis. We report two patients in whom it was used, on three separate occasions, to treat acute ventilatory failure following corrective spinal surgery. Non-invasive positive pressure ventilation may be useful postoperatively in high-risk patients undergoing major spinal surgery in an attempt to prevent intubation and its attendant complications. Non-invasive positive pressure ventilation (NIPPV) has been used in the treatment of both acute and chronic ventilatory failure secondary to a wide number of conditions, including chronic obstructive pulmonary disease (COPD) [1], neuromuscular disease [2], thoracoplasty and scoliosis [3]. When NIPPV is used in chronic ventilatory failure due to scoliosis, the benefits include improved arterial blood gases, improved quality of life and decreased hospital stay [4,5]. Approximately 80% of patients are alive on treatment 5 years after the initiation of non-invasive ventilation [4,5]. A number of studies have included small numbers of patients in whom NIPPV has been used to treat acute or chronic ventilatory failure secondary to scoliosis [6].Acute ventilatory failure can develop following corrective surgery for scoliosis, especially in those patients with poor pre-operative pulmonary function. Surgical intervention may be deemed contraindicated for patients with extremely limited respiratory reserve. We describe two cases of ventilatory failure following corrective surgery, in whom treatment with NIPPV obviated the need for intubation and conventional mechanical ventilation. Case history 1An 11-year-old boy with severe congenital scoliosis, first noted when aged 6 months, was admitted for corrective spinal surgery. At the age of 4 years, he had undergone anterior disectomies and excision of the vertebral end plates of the mid-thoracic spine. Unfortunately, this attempt to arrest spinal growth did not succeed and his scolotic deformity progressed. He was otherwise well and was on no medication.Pre-operatively, his main complaints were of back ache and exertional fatigue. Occasionally he experienced breathlessness on exertion but was able to play football. Examination revealed no signs of right heart failure or pulmonary hypertension and no neurological abnormality. His ECG and overnight oximetry were normal; his chest X-ray showed no parenchymal disease. Pre-operative lung function and arterial blood gases are shown in Table 1.He underwent the first stage of a Leatherman anterior wedge resection, which consists of an anterior transthoracic excision of a congenital thoracic hemivertebra via a ribexcising thoracotomy. He was electively ventilated via a tracheal tube on the intensive care unit (ICU) for 6 h postoperatively. He was extubated and observed overnight before transfer to a high-dependency unit (HDU) facility the next day, at which time oxygen saturation was 96% on 40% oxygen by a ...

SummarySpinal anaesthesia is generally preferred for Caesarean section. Its superiority for the baby is often assumed. Umbilical artery acid-base status provides a valid index of fetal welfare. Twenty-seven studies reporting neonatal acid-base data with different types of anaesthesia were used to compare umbilical artery or vein pH and base deficit, using random-effect meta-analysis. Cord pH was significantly lower with spinal than with both general (difference: )0.015; 95% CI )0.029 to )0.001; 13 studies, 1272 subjects) and epidural anaesthesia (difference )0.013; 95% CI )0.024 to )0.002; 11 studies, 828 subjects). Larger doses of ephedrine contributed to the latter effect (p = 0.023). Sixteen studies reported a base deficit, which was significantly higher for spinal than for general (difference 1.109; 95% CI 0.434-1.784 mEq.l )1 ; seven studies, 695 subject) and epidural anaesthesia (difference 0.910; 95% CI 0.222-1.598 mEq.l ; seven studies, 497 subjects). Spinal anaesthesia cannot be considered safer than epidural or general anaesthesia for the fetus. In labour, regional analgesia has a more favourable effect on the newborn than systemic analgesia [1][2][3], a fact that tends to be neglected by consumers and carers alike. By contrast, it is widely accepted that regional anaesthesia for Caesarean section is preferable to general anaesthesia. Spinal anaesthesia is commonly considered both more practical and safer than other techniques for the mother, and is therefore widely used [4]. It is often assumed, similarly, that spinal anaesthesia for Caesarean section must be better for the baby than general or epidural anaesthesia. There are several reasons for this assumption.• General anaesthesia was shown in the 1970s to depress the Apgar score, although this is reversible and rarely significant by 5 min [5,6].• Maternal hypotension, which is believed to be detrimental to fetal wellbeing, can be minimised by appropriate vasopressor control. Cardiac output, however, is more likely to be impaired by spinal than by epidural anaesthesia [7], is rarely measured and may not be so easily corrected.• The doses of drugs required to induce spinal anaesthesia are small and are therefore unlikely to produce systemic effects in the baby. With the brief duration of anaesthesia before delivery of the baby, however, pharmacological fetal depression is likely to be less important than that following prolonged maternal administration of depressant drugs, as may occur during labour. It must be borne in mind, moreover, that drugs may affect the baby in two ways: firstly via a direct effect, resulting from placental drug transfer, which is transient even when general anaesthesia is used for Caesarean section, and clearly unimportant with spinal anaesthesia; and secondly, through an indirect effect resulting from maternal physiological or biochemical changes, which Anaesthesia, 2005, 60 , pages 636-653 .........................................................................................................................................

Objective To examine potentially modifiable factors that may influence the high maternal and perinatal mortality associated with caesarean section in Malawi.

Report of the joint working party on medical senrices for children.

SummaryUpper oesophageal sphincter pressure has been measured in 24 patients with a sleeve device. The median sphincter pressure when awake was 38 mmHg. and when anaesthetised and paralysed was 6 mmHg. Afier tracheal intubation, cricoid pressure was applied at measured values between 5 and 50 N using a hand-held cricoid yoke while the sphincter pressure was recorded in two head and neck positions: with and without a standard intubating pillow with neck support. A cricoid ,force of 40 N increased sphincter pressure to above 38 mmHg in all the patients and the use of'the pillow did not alter this effect. With the application of' cricoid pressure, operating department assistants raised sphincter pressure to above 38 mmHg in only 50% of patients. Laryngoscopy made little dijerencp to the effect of cricoid pressure except in one patient in whom it reduced the sphincter pressure by 27 mmHg.

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Objectives: To assess in a prospective randomised study the association between motor block resulting from high and low dose epidural infusions of bupivacaine in labour and the incidence of long term backache after childbirth, and to compare the incidence of backache in women not receiving epidural analgesia. Design: Women requesting epidural analgesia in labour between October 1991 and March 1994 were randomised to receive infusions of either bupivacaine alone or low dose bupivacaine with opioid. Data were collected during labour and the immediate postpartum period from these women and from women recruited at random over the same time from those who had laboured without epidural analgesia. A postal questionnaire about symptoms was sent three months after childbirth to all women. Further data were collected one year after childbirth from those who had reported new backache at three months. Setting: St Thomas's Hospital, London. Subjects: 599 women were recruited, of whom 450 (75%) replied to a follow up questionnaire. Results: 152 women (33.8% of responders) reported backache lasting three months after delivery and, of these, 33 (7.3%) had not previously suffered with backache. There were no significant differences between the treatment groups in the incidence of postnatal backache overall or of new backache or any symptoms after childbirth. Among all demographic, obstetric, and epidural variables examined the only factors significantly associated with backache after childbirth were backache before and during pregnancy. Conclusions: The incidence of new long term backache was not significantly increased in women who received epidural analgesia in labour. Motor block resulting from epidural local anaesthetic administration was not a significant factor in the development of backache. Key messages About half of all women suffer backache during pregnancy, but many forget this when questioned retrospectively A prospective study showed that the incidence of new postpartum backache is 7.3 The use of epidural analgesia in labour had no effect on the incidence of postpartum backache In a randomised trial motor block in labour was not associated with an increase the incidence of backache

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