Anaesthesiiz vol26 no I January I971 blood. After the new liver is revascularised, glucose and potassium levels in the blood fall and supplements are needed. The ice-cold donor liver produces a sudden, but limited, drop in body temperature. Conventional relaxant and nitrous oxide technique has proved successful in 23 patients. Strict attention must be paid to monitoring of arterial and venous pressures, ECG, body temperature, urine output and acid-base, glucose and potassium levels. Replacement of lost blood and recording of fluid-balance must be meticulous. An experienced team consisting of at least two anaesthetists, a nurse and operating theatre and biochemistry technicians is needed.Mechanical or spontaneous ventilation in the sitting position for neurosurgery? R. A. Miller New Addenbrooke's Hospital, Cambridge The sitting position for neurosurgical procedures in the posterior cranial fossa and upper cervical region presents a formidable challenge to the anaesthetist. There is continuing controversy regarding the safety of the posture and whether the theoretical and practical advantages of mechanical ventilation outweigh the alleged value of spontaneous respiration as a guide to surgical encroachment on the medulla and brain stem. Retrospective consideration has therefore been given to a consecutive, unselected series of 1 10 patients operated on in one neurosurgical unit for lesions in the posterior cranial fossa (93) and upper cervical region (17). Pulmonary ventilation was controlled (IPPV) in 55 patients and was spontaneous in the remainder. Halothane was the usual anaesthetic. Continuous ECG monitoring was used in all patients during surgery. There was no mortality during operation.On average, arterial pressure was lower during mechanical than during spontaneous ventilation, the lowest levels usually being reached at the start of IPPV in the sitting position. Acknowledgement of this fact and, of the necessity for the continuous or intermittent use of vasopressors, were the most critical factors determining whether or not IPPV was preferred by an individual anaesthetist. Methoxamine, repeated as necessary in doses of 2-4mg, or the slow infusion of phenylephririe (10-20mg/500ml) effectively opposed arterial hypotension. Vasopressors were required rarely in seated patients breathing spontaneously.In the group ventilated mechanically, 15 patients showed circulatory changes associated with surgery, usually near the brain stem; the commonest change was bradycardia.Twenty-one of the 55 patients breathing spontaneously showed cardiovascular or respiratory changes coincident with surgical manipulation; in 2 cases only, hyperpnoea occurred without other signs, whereas a change in heart rate or ECG pattern was observed in 6 patients who showed no respiratory alteration.The true incidence of air embolus cannot be established from this series but was suspected during operation (and from the post-operative course) in one patient breathing spontaneously.So far as any sequelae of the anaesthetic technique could be asse...
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