Two patients suffered barotrauma whilst undergoing transtracheal jet ventilation (TTJV). In the first, TTJV was provided by a Sanders injector and in the second it was given by a high frequency jet ventilator. Barotrauma was a consequence of the expiratory pathway becoming blocked. The mechanism of barotrauma and a method of airway pressure monitoring during TTJV are discussed. It is recommended that meticulous care is taken to ensure an adequate path for expiration when jet ventilation is used.

SummaryWhile some speculation surrounds annual private practice incomes of anaesthetists, little is known of the hours of work needed to generate any presumed income (the hourly rate). The benefit maxima of five private medical insurers are published in fee schedules and data on the duration of common operations are now also known. In this study we combined these to generate estimates for hourly rates of reimbursement across 78 common operations in eight surgical subspecialties, for anaesthetists and surgeons. We expected to find significant differences between insurers as a result of market competition, and we expected differences between anaesthetists and surgeons. The median (IQR [range]) rate of reimbursement for anaesthetists was £167 (132-211 [68-570]).h )1 with significant variation across subspecialties (p < 0.001); for example, cardiac surgery was best reimbursed at £283 (257-308 [229-398] . Contrary to expectations, the rates of payment to anaesthetists by insurers were similar (p > 0.17). Patterns of reimbursement for surgeons were similar to those for anaesthetists, except that surgeons were reimbursed at about twice the rate. We conclude there is a confluence of insurer reimbursement levels and we discuss potential implications of this finding. Our results also have implications for how incentives between the NHS and private practice, or within a private practice group, might be optimally managed.

SummaryA new lightweight device for the detection of placement of a tracheal tube in the trachea or oesophagus is described. The device utilises a sonic technique detecting resonating frequencies in an open (trachea) or closed (oesophagus) structure. Evaluation of the device in a clinical environment is described and it has been shown to be capable of verifying the correct placement of the tracheal tube in the trachea in 98% of patients studied. Further evaluation of this intubating aid appears justijied.

Regional analgesia has advantages over general anaesthesia for some procedures on the upper limb but, for a local technique to be acceptable to both surgeon and anaesthetists it must be reliable and safe. The search for an approach to the brachial plexus which fulfills these criteria has been a long one.Halsted first operated under brachial plexus block, when, in 1884, he exposed the nerve roots in the neck and blocked them with direct application of cocaine solution. The first percutaneous approaches were in 191 1 when Hirschel' injected the plexus through the axilla and then Kulenkampff used a supraclavicular approach. The main disadvantage of brachial plexus block was the uncertainty of success and the 1943 monograph by Macintosh & Mushin3 describes four approaches.Burnham4 observed the nerves of the plexus and their close relationship to the brachial artery in an 11-year-old boy who had a laceration of the axilla, and described the existence of a perivascular space enclosed by a fascia1 sheath. He went on to carry out a number of blocks by injecting each nerve within the sheath. Eather5 pointed out that the only landmark required was the pulsation of the axillary artery. De Jong6 showed the importance of injecting a sufficient volume of anaesthetic solution in order to block the nerves arising from the plexus proximal to the site of injection, but continued to use multiple injections into the space.Winnie & Collins7 illustrated with radio-opaque dye injections that the perivascular space was a continuous fascia-enclosed space extending from the cervical transverse processes to several centimeters beyond the axilla and developed the subclavian perivascular technique with a single injection and a large volume of anaesthetic solution. This approach, however, was still supraclavicular with the needle pointed caudally and carried the risk of subclavian artery puncture and pneumothorax, although the incidence of these complicatioiis is greatly reduced by experience.In an effort to improve still further the scope and safety of brachial plexus block, Winnie8 approached the 'brachial plexus sheath' higher in the neck via the interscalene space opposite C6. He showed that it was possible at this level to produce excellent anaesthesia of the upper limb and shoulder girdle without risk to the subclavian artery or the cupola of the lung.M. E. Ward, MB, BS, Registrar, Department of Anaesthesia, King's College Hospital, London SE5 9RS. The work described in this paper was undertaken at Centrallasarrettet, Vasteras, Sweden.

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