Low-pressure pneumoperitoneum is feasible for LC and minimizes the adverse hemodynamic effects of peritoneal insufflation.

In a double-blind, randomized, controlled prospective study, 30 grade ASA I/II patients received a continuous i.v. infusion of normal saline or esmolol hydrochloride before induction of anaesthesia and tracheal intubation. Arterial pressure and heart rate were measured to assess the pressor response to laryngoscopy and intubation. The heart rate decreased in the esmolol group before induction of anaesthesia. The pressor response to laryngoscopy was significantly less marked in the esmolol group.

SummaryForty ASA 1 patients presenting for minor gynaecological surgery were randomly allocated into four study groups to compare the haemodynamic effects of adding diyerent doses of ephedrine to an induction dose of propofol. Heart rate, oxygen saturation and non-invasive arterial blood pressure were monitored before and for Smin after induction. In those patients who received propofol alone, there was a significant decrease in both systolic (p < 0.001) and diastolic (p = 0.003) blood pressure. The addition of ephedrine 15 mg or 20 mg to 1 % propofol20 ml was very effective in maintaining blood pressure at pre-induction values. There was a statistically significant increase from baseline in systolic @ = 0.004) and diastolic (j = 0.031) pressures, but this only occurred at 1 min postinduction. The addition of ephedrine 10 mg was insuficient to prevent hypotension. There was no signijcant effect on either heart rate or oxygen saturation in any group. We conclude that ephedrine may be safely employed to reduce the degree of hypotension during induction with propofol in this patient group. Key wordsAnaesthetics, intraveneous; propofol. Sympathetic nervous systems; pharmacology, ephedrine.Propofol has gained widespread popularity as an induction agent because of the ease and reliability of its use together with its short duration of action and minimal hangover effect. It can, however, cause hypotension and bradycardia [I, Ephedrine has been used for many years to counteract similar problems in spinal and epidural anaesthesia [lo]. In addition to its a vasoconstrictor and fl cardiac stimulant effects, ephedrine also has the advantage of being shortlived, so giving it a similar action profile to propofol. We assessed the haemodynamic effects of adding various doses of ephedrine to propofol to obtund this response and to determine the optimal dose. As propofol is known to have a hypotensive action even in young, fit individuals, we decided to assess the safety and efficacy of this combination in ASAl patients. MethodsAfter obtaining approval from the local ethics committee, and with informed consent, we studied 40 unpremedicated ASAl patients presenting for minor gynaecological surgery. Following insertion of an intravenous cannula, monitoring of arterial blood pressure (non-invasive), electrocardiograph (ECG), and peripheral oxygen saturation (Spo?) was instituted for up to 5 rnin before induction, or until the measured parameters were stable. Anaesthesia was induced with one of the study treatments shown in Table 1, allocated in random order. A dose sufficient to obtund the eyelash reflex was given over 40s and the amount recorded. Patients then breathed a mixture of 60% nitrous oxide in oxygen during the study period and before the start of surgery. The ECG and Spa? were monitored continuously and arterial blood pressures recorded at 1 min intervals for up to 5 min after injection of the induction agent. Two anaesthetists were present during the whole of the study period, and the administering anaesthetist was una...

Patient-controlled sedation (PCS) with propofol has been used successfully as an adjunct to local anaesthetic procedures. We studied a group of elderly patients (mean age 75.4 yr) undergoing cataract surgery and attempted to increase patient acceptability and comfort of local anaesthesia. Propofol was self-administered in a dose of 0.25 mg kg-1 for patients more than 60 yr of age, with a lockout period of 3 min. A total of 14 of 20 patients used PCS; eight of 20 used the PCS only once and another six had three tries or less. Despite this, 18 of 20 patients claimed they found the PCS useful. However, while it is possible to administer PCS successfully to elderly patients undergoing cataract surgery and produce a decrease in the level of anxiety, we found it unacceptable because of head movement in two patients. These patients received only two and three divided doses, to a maximum of 29 and 30 mg, respectively. There were no other adverse events.

We have compared codeine and tramadol in a prospective, double-blind study of postoperative analgesia in 75 patients after elective intracranial surgery. Twenty-five patients received codeine 60 mg, tramadol 50 mg or tramadol 75 mg i.m. Patients receiving codeine had significantly lower pain scores over the first 48 h after operation (P < 0.0001). Although there was no difference in visual analogue scale (VAS) scores between the three groups at 24 h, the codeine group had significantly lower scores at 48 h (P < 0.0001). The tramadol 75 mg group had significantly higher scores for both sedation and nausea and vomiting (P < 0.0001 for both scores). We conclude that codeine 60 mg i.m. provided better postoperative analgesia than tramadol after craniotomy and that tramadol 75 mg should be avoided because of its side effects of increased sedation and nausea and vomiting.

In order to test the hypothesis that urine colour can be used as an index of hydration in critically ill patients, we selected 40 intensive care and high‐dependency patients and correlated urine colour (scored on an eight‐point scale) with various indices of hydration: urine:plasma sodium, osmolality and urea ratios, urine output and central venous pressure. In addition, we compared the colour‐chart score with scores made by intensive care nurses (without the benefit of a colour chart) in order to test subjective assessment of urine colour. There were weak but statistically significant correlations between urine colour and urine output (Spearman's r = − 0.555) and between urine colour and urine:plasma sodium ratio (Spearman's r = − 0.459). Subjective assessment of urine colour appeared to be reliable. Thus, although urine colour does vary with hydration in the critically ill, assessment of urine colour adds little to the overall assessment of hydration in this group of patients.

SummaryThe Combitube airway allows short-term ventilation during cardiopulmonary resuscitation and can be useful in the management of the difficult airway. In a prospective observational study we assessed its use during percutaneous dilatational tracheostomy (PDT). Twenty-one intensive care patients scheduled for elective PDT had their tracheal tube replaced by a Combitube airway retaining the same ventilator settings. Arterial blood gases, airway pressures, SpO 2 and end-tidal CO 2 were measured as were the transmural pressures exerted by the Combitube cuffs. Combitube placement was successful in 20 of 21 patients although adequate ventilation was possible in only 17 (85%). There was no significant change in PaO 2 , SpO 2 , end-tidal CO 2 , PaCO 2 or mean airway pressure during Combitube ventilation. A high mean (SD) transmural pressure of 14.7 (5) kPa was exerted by the distal cuff. The Combitube provided a satisfactory alternative airway to the tracheal tube during performance of PDT in 85% of our patients. Potential problems associated with its use in intensive care patients are outlined.

SummaryWe present a woman in her first pregnancy, with known aortic stenosis prior to conception, who successfully underwent regional anaesthesia for an elective Caesarean section using a subarachnoid microcatheter. The anaesthetic management of patients with aortic stenosis requiring noncardiac surgery is a complex and contentious matter, particularly when the situation is compounded by the physiological changes accompanying pregnancy and delivery. This is the first reported use of a subarachnoid microcatheter in such a patient. The choice of technique is discussed and compared with other options for providing anaesthesia. Patients with aortic stenosis are at risk of increased morbidity and mortality when undergoing anaesthesia [1]. Their compensatory left ventricular hypertrophy renders them vulnerable to ischaemia and they are difficult to resuscitate [2]. The added stress of the physiological changes of pregnancy and delivery can result in an unstable situation with maternal mortality being quoted as 17% and a perinatal mortality of 32% [3]. The choice of anaesthetic should be appropriate to the well-being of both mother and fetus. There are very few reports in the literature regarding the anaesthetic management of patients with aortic stenosis requiring delivery by Caesarean section [4][5][6][7] and the successful use of a subarachnoid microcatheter for this procedure has not been previously reported. Case historyA 21-year-old Asian primigravida, known to have aortic stenosis, presented for an elective Caesarean section at 36 weeks gestation. Prior to conception she had been under review by a cardiologist and at this time she had no cardiac-related symptoms and was otherwise fit and well. She was noted to have an ejection systolic murmur graded 4/6 and a pressure gradient across the valve, estimated by echocardiography, of 48 mmHg. Her electrocardiograph (ECG) was normal.Her pregnancy had progressed uneventfully and, when reviewed by the cardiologist at 16 weeks gestation, she was normotensive, in sinus rhythm and there had been a slight increase in her pressure gradient to 57 mmHg. The echocardiograph showed good left ventricular function with no significant hypertrophy. The decision was made by her consultant obstetrician to deliver the baby by Caesarean section at 36 weeks gestation and she was referred for an anaesthetic opinion.Twenty-four hours prior to surgery she was found to be fit and well, in sinus rhythm, normotensive and with no signs or symptoms of cardiac failure. After a full discussion with the patient and having explained the advantages and disadvantages of both general and regional anaesthesia it was decided to employ a regional anaesthetic technique. It was felt that the use of a spinal microcatheter would allow precise titration of local anaesthetic to effect and thereby minimise physiological changes.Following an overnight fast and routine gastric acid prophylaxis, the patient was transferred to the delivery suite anaesthetic room. A 14 gauge peripheral cannula was inserted under local...