We have compared iontophoretically and locally applied lidocaine for relief of pain on propofol injection. Pain was assessed on insertion of a 20-gauge i.v. cannula and at 10-s intervals for 30 s after injection of propofol. Pain scores on cannulation were significantly less in the iontophoresis group (median 1.1) than in the sham (control) group (median 2.8) (P < 0.005). Pain after injection of propofol was significantly reduced at 10 (P < 0.002), 20 (P < 0.001) and 30 s (P < 0.001). We conclude that iontophoretically applied lidocaine decreased the pain of cannulation and propofol injection.
SummaryWe compared the effect of alfentanil 10 mg.kg 21 and esmolol 1.5 mg.kg 21 on the cardiovascular responses to laryngoscopy and double-lumen endobronchial intubation in two groups of 20 ASA 2±3 patients undergoing pulmonary surgery, in a randomised double-blind study. Arterial pressure and heart rate decreased after induction of anaesthesia and increased after intubation in both groups (p , 0.05) but remained at or below baseline values, and changes were comparable in both groups. Plasma catecholamine concentrations decreased after induction of anaesthesia in both groups (p , 0.05). Epinephrine concentrations increased in the esmolol group after intubation (p , 0.05) but remained below baseline in the alfentanil group (p , 0.05). Norepinephrine concentrations increased significantly in both groups after intubation but were higher in the esmolol group (p , 0.05). Although both esmolol 1.5 mg.kg 21 and alfentanil 10 mg.kg 21 similarly attenuated the arterial pressure and heart rate response to endobronchial intubation, plasma catecholamine concentrations increased in the esmolol group to values greater than previously reported after tracheal intubation. Laryngoscopy and intubation with a double-lumen endobronchial tube is accompanied by increased heart rate, arterial blood pressure and plasma catecholamine concentrations [1], mediated by increased sympathetic nervous activity [2,3]. The increases in heart rate and arterial pressure are of similar magnitude and duration to the well-described responses to laryngoscopy and tracheal intubation, i.e. mean increases of 15±20 beats.min 21 and 30±40 mmHg, respectively, for approximately 5±6 min. These responses may result in myocardial ischaemia in susceptible individuals [4], and patients presenting for surgery which requires double-lumen endobronchial intubation (mostly pulmonary surgery) are a high-risk group for coexisting ischaemic heart disease. We have previously shown that the haemodynamic changes to double-lumen endobronchial intubation were attenuated by the administration of intravenous esmolol 1.5 mg.kg 21 [1]. However, plasma norepinephrine concentrations were significantly increased after intubation in those who received esmolol compared with control subjects, suggesting that although esmolol diminished the endorgan response to intubation, sympathetic nervous system activity was increased. This may be because esmolol, by decreasing the haemodynamic changes, prevented a baroreflex-mediated inhibition of central sympathetic activity, which occurred in the control group.Several drugs have been shown to attenuate the cardiovascular responses to laryngoscopy and intubation [3] and intravenous opioids, e.g. alfentanil [5,6]
SummaryWe investigated the long-term effects on clinical practice of a simulation-based course in anaesthesia crisis management. A questionnaire was posted to all anaesthetists who had attended a course in the preceding year. The response rate was 69% (66 ⁄ 96). The crisis management course was valued highly by respondents, who perceive a change in practice as a result of the training. This change in practice was not limited to the specific clinical events simulated in the course, but applied to a wide range of events and to routine practice. The high rate of subsequent critical events reported in the survey supports the need for training in this area. This survey suggests that simulation-based training in crisis management is an effective form of continuing medical education for anaesthetists.
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