The antiemetic action of stimulation of the P6 (Neiguan) acupuncture (ACP) point has been studied in women, premedicated with nalbuphine 10 mg, undergoing minor gynaecological operations under methohexitone-nitrous oxide-oxygen anaesthesia. Invasive ACP--manual or electrical at 10 Hz--applied for 5 min at the time of administration of the premedication markedly reduced the incidence of vomiting and nausea in the first 6 h after operation, compared with untreated controls. This did not occur with stimulation of a "dummy" ACP point outside the recognized ACP meridians. Non-invasive methods (stimulation via a conducting stud or by pressure) were equally as effective as invasive ACP during the early postoperative period. However, both these non-invasive approaches were less effective than invasive ACP in the 1-6 h postoperative period, although each was as effective as two standard antiemetics (cyclizine 50 mg, metoclopramide 10 mg). In view of the total absence of any side effects in more than 500 ACP procedures, the clinical applications of this finding are worthy of further study.

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This study investigates the effect on the heart and blood vessels of various rates of administration of boluses of a relatively new potent opiate, remifentanil, to patients with coronary artery disease. The results show that remifentanil should be given only by slow infusion to such patients.

SummaryWe report the results of a study comparing two dose regimens of the gastric antisecretory agent I omeprade, used

SummaryTwo comparable series of 21 patients who had elective Caesarean section had general anaesthesia induced by thiopentone sodium 4.53 (SD 0.65) mglkg or propofol2.15 (SD 0.26) mglkg. Maintenance was similar for both groups. Blood pressure was lower in the propofol group during the induction-delivery interval. Umbilicallmaternal vein ratios for thiopentone and propofol were 8.5 and 7.2 respectively. Infant wellbeing as judged by Apgar score and cord blood analysis showed little difference between the two induction agents. Factors associated with uterine relaxation and bleeding were similar in the two groups. Key wordsAnaesthesia; obstetric. Anaesthetics intravenous; thiopentone sodium, propofol.Thiopentone sodium has been used in obstetric anaesthesia since 1936l and is regarded as the standard induction agent. Early investigators used larger doses and Hellman et aL2 showed that considerable quantities were transferred to the infant. It was later demonstrated3 that placental transfer occurred within seconds and that repeated injection caused significant infant depres~ion.~ Present-day opinion is that a single dose of 3-5 mg/kg5s6 should be given to induce sleep and that maintenance of anaesthesia before delivery should be by inhalation agents.Propofol, diisopropyl phenol, has properties which suggest that it might be a useful alternative to thiopentone. The suspension has a pH of 7.0 which makes it less likely to cause local tissue or vascular complications. The cardiovascular response to tracheal intubation is less than with thiopentone.' Propofol is more rapidly metabolised and excreted than the barbiturate, and hangover after anaesthetic is reduced.8This investigation reports a comparison of propofol and thiopentone used as induction agents for general anaesthesia for patients who have elective Caesarean section. It had the approval of the Local Medical Research Ethics Committee and verbal consent from all patients. Materials and methodsWomen selected were healthy and had a pregnancy of at least 36 weeks' gestation with a single uncompromised fetus. Elective Caesarean section was for disproportion or abnormal fetal presentation. Oral ranitidine 150 mg was given 90 to 120 minutes before anaesthesia and left lateral tilt, instituted 15 minutes before induction, was maintained until delivery. Two intravenous cannulae were introduced, one in the right arm for the infusion of a compound sodium lactate solution and the other in the left arm for blood sampling. The ECG, blood pressure automatically by Dinamap recorder, and tissue oxygen saturation by pulse oximeter, were monitored before and during anaesthesia. Ventilation of the lungs during anaesthesia was adjusted to maintain an end-tidal carbon dioxide of 4 to 4.25 kPa using a Datex Normocap. All patients were preoxygenated with 100% oxygen for 5 minutes before induction, and cricoid pressure was applied from the start of injection of the induction agent until tracheal anaesthesia was established.Women were randomly allocated to receive either 2.5% thiopenton...

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The benzodiazepine antagonist flumazenil (0.01 mg/kg) has been compared with doxapram (1 mg/kg) and saline for the reversal of anaesthesia with intravenous midazolam, alfentanil, nitrous oxide in oxygen and isoflurane. The completeness of reversal was assessed by means of a four-choice reaction time test, 1 and 3 h following the antagonist. In addition, the level of sedation was graded using a five-point scale. Psychomotor testing showed that 60 min after administration of the antagonist, there were marked increases in reaction times (P less than 0.05) both in the control and doxapram groups, but not in those receiving flumazenil. At 180 min, however, reaction times in all groups had returned to baseline values. In contrast, there was a significant difference in the sedation scores between the saline and flumazenil groups throughout the study period (P less than 0.05). During the 4 h following midazolam, there was no evidence of re-sedation in any of the groups despite the relatively high midazolam dosage.

INTRODUCTION: A 67-year-old-male with history of dysphagia was found to have a subepithelial mass in the gastric cardia. It was located anterolaterally along the greater curvature and had normal overlying mucosa. Endoscopic ultrasound demonstrated a 17 mm hypoechoic homogenous lesion arising from the muscularis propria without malignant features (Figure 1). It was most consistent with a leiomyoma. After discussion of the findings and management options, our patient elected to proceed with endoscopic resection. CASE DESCRIPTION/METHODS: A single-channel endoscope identified the lesion on retroflexion. After submucosal injection of 0.9% normal saline, methylene blue, and epinephrine, a transverse incision was made in the midsection of the bulging mass, exposing the submucosa. Repeated injections lifted the submucosa for dissection using a T-type hybrid knife. An IT-2 knife (Olympus®) was used to cut the submucosa in a circumferential fashion around the tumor. It was bilobar in appearance (Figure 2) and significantly larger than seen on EUS. All bleeding vessels were cauterized, and a large snare was used to perform en bloc resection of the tumor. We used a transverse midline incision to facilitate resection while minimizing disruption of the overlying mucosa. No mucosa was excised, and the incision was easily approximated for closure using multiple endoclips. The tumor was pale in appearance with an intact capsule. It measured 25 mm at its greatest diameter, which was 8 mm larger than EUS measurement. Histologic examination revealed bland spindle cell proliferation (Figure 3). Immunohistochemical staining was positive for actin and desmin and negative for CD117 and CD34, features consistent with leiomyoma. DISCUSSION: Endoscopic surgery is rapidly advancing, providing safe and feasible alternatives to more invasive therapies. We describe successful endoscopic full-thickness resection (EFTR) of a gastric cardia mass whose size and shape were significantly underestimated on pre-operative EUS. We have encountered this in prior cases, most notably lesions originating in the third and fourth gastric layers. Resection of our patient's gastric cardia tumor made this discrepancy particularly challenging, and it is a pitfall of EUS that even the most experienced endosonographers must be cognizant of.