Postoperative nausea and vomiting (PONV) are major problems after gynaecological surgery. We studied 40 patients undergoing total abdominal hysterectomy, allocated randomly to receive opioid-free epidural-spinal anaesthesia or general anaesthesia with continuous epidural bupivacaine 15 mg h-1 or continuous bupivacaine 10 mg h-1 with epidural morphine 0.2 mg h-1, respectively, for postoperative analgesia. Nausea, vomiting, pain and bowel function were scored on 4-point scales for 3 days. Patients undergoing general anaesthesia had significantly higher nausea and vomiting scores (P < 0.01) but significantly lower pain scores during rest (P < 0.05) and mobilization (P < 0.01). More patients undergoing general anaesthesia received antiemetics (13 vs five; P < 0.05), but fewer received supplementary opioids on the ward (eight vs 16; P < 0.05). We conclude that opioid-free epidural-spinal anaesthesia for hysterectomy caused less PONV, but with less effective analgesia compared with general anaesthesia with postoperative continuous epidural morphine and bupivacaine.
Background: Inflammation-associated proteinuria in acute, nonrenal disease is a common but poorly understood phenomenon. We performed an observational study of the urinary excretion of orosomucoid (␣ 1 -acid glycoprotein), albumin, ␣ 1 -microglobulin (protein HC), and IgG to obtain quantitative and temporal data on these 4 proteins. Methods: Urine samples were collected at daily intervals for up to 23 days from 6 patients with surgeryinduced inflammation and at hourly intervals for a 24-h period from 7 sepsis patients. Urinary protein concentrations were assessed by immunoturbidimetry. Results: During surgery-induced inflammation, the increase and decrease in orosomucoid excretion mirrored changes in plasma C-reactive protein. Values for all 4 urinary proteins were increased in sepsis patients. The observed maximum increases in urinary protein excretion relative to the upper reference values were 280-fold for orosomucoid, 98-fold for ␣ 1 -microglobulin, 33-fold for albumin, and 26-fold for IgG. Conclusions: Orosomucoid, usually present in plasma and urine in much lower concentrations than albumin, is increased in urine to concentrations equal to or higher than albumin in proteinuria associated with acute inflammation. The pathophysiologic mechanisms responsible for this markedly increased excretion are unknown. Monitoring of urinary excretion of orosomucoid and other specific proteins, expressed as protein/creatinine ratios, may provide a window for clinically rele-
Twenty cases of severe bradycardia, including 12 cases of cardiac asystole, following administration of a single dose of suxamethonium to 17 adult patients are presented. Treatment consisted of i.v. atropine in 16 cases, and in four cases external cardiac massage or a precordial thump was also given. Remission was complete in all cases. The mechanism is not known, but it is suggested that i.v. administration of fentanyl at induction may enhance the tendency to bradycardia following suxamethonium. Absence of preoperative atropine may also be of importance.
Background: The aim of this study was to test the hypothesis that a new mode of ventilation (pressure-regulated volume control; PRVC) is associated with improvements in respiratory mechanics and outcome when compared with conventional volume control (VC) ventilation in patients with acute respiratory failure. We conducted a randomised, prospective, open, cross over trial on 44 patients with acute respiratory failure in the general intensive care unit of a university hospital. After a stabilization period of 8 h, a cross over trial of 2 × 2 h was conducted. Apart from the PRVC/VC mode, ventilator settings were comparable. The following parameters were recorded for each patient: days on ventilator, failure in the assigned mode of ventilation (peak inspiratory pressure > 50 cmH 2 O) and survival. Results: In the crossover trial, peak inspiratory pressure was significantly lower using PRVC than with VC (20 cmH 2 O vs 24 cmH 2 O, P < 0.0001). No other statistically significant differences were found. Conclusions: Peak inspiratory pressure was significantly lower during PRVC ventilation than during VC ventilation, and thus PRVC may be superior to VC in certain patients. However, in this small group of patients, we could not demonstrate that PRVC improved outcome.
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