Both epidural and paravertebral blocks are effective in controlling post-thoracotomy pain, but comparison of preoperative and balanced techniques, measuring pulmonary function and stress responses, has not been undertaken previously. We studied 100 adult patients, premedicated with morphine and diclofenac, allocated randomly to receive thoracic epidural bupivacaine or thoracic paravertebral bupivacaine as preoperative bolus doses followed by continuous infusions. All patients also received diclofenac and patient-controlled morphine. Significantly lower visual analogue pain scores at rest and on coughing were found in the paravertebral group and patient-controlled morphine requirements were less. Pulmonary function was significantly better preserved in the paravertebral group who had higher oxygen saturations and less postoperative respiratory morbidity. There was a significant increase in plasma concentrations of cortisol from baseline in both the epidural and paravertebral groups and in plasma glucose concentrations in the epidural group, but no significant change from baseline in plasma glucose in the paravertebral group. Areas under the plasma concentration vs time curves for cortisol and glucose were significantly lower in the paravertebral groups. Side effects, especially nausea, vomiting and hypotension, were troublesome only in the epidural group. We conclude that with these regimens, paravertebral block was superior to epidural bupivacaine.

Summary Six patients undergoing paravertebral blocks for chronically painful conditions Key wordsEquipment; thermal imaging. Anaesthetic techniques, regional; paravertebral block.Paravertebral analgesia is advocated for surgical procedures of the abdomen wherever the afferent input is predominantly unilateral e.g. nephrectomy, cholecystectomy, but it is particularly effective when used to treat the pain of posterolateral thoractomy [ 11. However, despite numerous studies showing the clinical safety and efficacy of this block [ 1-51, there appear to be some reservations which have been voiced in vague terms by some [6, 71 and more specifically by others [8]. The former include the suggestion that the technique is hazardous and ineffective and the latter that paravertebral spread rarely exceeds two dermatomes with evidence of sympathetic blockade being seen in fewer than 5% of patients. Rather than simply add further anatomical data, we undertook an objective physiological assessment of the extent of the somatic and sympathetic blockade achievable with a single percutaneous paravertebral injection. Patients and MethodsThe study was approved by the hospital ethics committee and informed consent was 'obtained from all patients. Percutaneous paravertebral blocks were perfonned in six patients presenting for treatment of chronically painful chest wall conditions (post-thoracotomy neuralgia, intercostal neuralgia and postherpetic neuralgia). Each patient underwent pre-operative automated cardiovascular data collection consisting of noninvasive pulse and blood pressures in the sitting and supine positions (Datascope 22001). Anterior, posterior and lateral thermographic control views of the naked trunk and limbs were obtained pre-operatively with a Starsight thermal imaging camera (Insight Vision Systems, Malver). Pre-operative pinprick testing was normal in all patients. The blocks were performed by a single operator experienced in this technique (J.R.) and the method used was that of Eason and Wyatt [2] supplemented with radiographic screening and the use of radio-opaque contrast medium. Following negative aspiration, 15 ml of 0.5% bupivacaine was injected over 60 s as a single bolus (with multiple aspirations) at a mean dermatomal level of T,,, with a range of T,-, to T,,,, . Postinjection data collection was undertaken by two observers (D.I. and S.P.S.C.) and consisted of pinprick mapping of the extent of the block, repeated thermographic imaging at 5min intervals until a stable image was obtained, 5min sitting and lying cardiovascular parameters and documentation of any side effects.

SummaryWe studied 128 patients undergoing nasal intubation to see whether the nostril side used influenced peri-operative nasal complications. In the apparently normal nostril, there is no significant difference between either nostril in difficulty of intubation ( p . 0.8). Similarly, there is no significant difference in the incidence of bleeding at intubation ( p . 0.2), at extubation ( p . 0.5) and once the patient has returned to recovery ( p . 0.1). Postoperative nostril patency is also similar between groups ( p . 0.85). Standard teaching of nasal intubation recommends that, in the first instance, the right nostril should be used when patency appears equal on both sides of the nose [1]. This is because the tracheal tube is designed such that the flat side of the bevel is on the left side of the tip. However, there is no evidence that the risk of trauma to the nose, or difficulty with intubation, is any greater using the left nostril. Many case reports of potentially serious complications of nasal intubation have in fact involved the right nostril [2±4].Our study aimed to elucidate whether the left nostril was more difficult to intubate than the right and whether the complications, in terms of bleeding and postoperative nostril patency, were different between the two sides. MethodAfter approval from the Hospital Research Ethics Committee, we studied 128 patients who were undergoing elective dental surgery that required nasal intubation. Patients were ASA classification 1 or 2. They had no history of nasal disease, including epistaxis, no coagulation problems, and were not taking medication likely to increase bleeding. None of the group had hypertensive disease. Patients were not studied if there was apparent unilateral decrease in nostril patency, determined by breathing through each nostril individually.A standard anaesthetic technique was used. Premedication with diclofenac 100 mg rectally was given up to 30 min before surgery. Induction and maintenance of anaesthesia was performed using a combined propofol (500 mg)/alfentanil (2 mg) infusion, with atracurium 0.3 mg.kg 21 given to facilitate intubation. Ventilation throughout anaesthesia was provided using an oxygen/ nitrous oxide mixture.The nostril side for intubation was chosen randomly and no vasoconstrictor spray was used. Intubation was performed using a Portex`Ivory' cuffed nasotracheal tube lubricated with water-soluble jelly. A tube with an internal diameter of 6.5 mm was used for men and 6 mm for women. The tube was passed through either nostril with the slant of the bevel facing to the left. The ease of passing the tube through the nostril was noted. Once the tip of the tube had passed into the oropharynx, direct laryngoscopy was performed and the presence of blood in the pharynx was noted. This was classified as either (1) blood absent, (2) blood staining on the cuff only (mild bleeding) or (3) blood pooling on the posterior pharyngeal wall (severe bleeding). The tube was then passed into the trachea under direct vision, the cuff was inflated ...

Epilepsy is the most common serious neurological disorder, with a prevalence of 0.5-1% of the population. While the traditional antiepileptic drugs (AEDs) still play a significant role in treatment of seizures, there has been an influx of newer agents over the last 20 yr, which are now in common usage. Anaesthetists are frequently faced with patients with epilepsy undergoing emergency or elective surgery and patients suffering seizures and status epilepticus in the intensive care unit (ICU). This review examines perioperative epilepsy management, the mode of action of AEDs and their interaction with anaesthetic agents, potential adverse effects of anaesthetic agents, and the acute management of seizures and refractory status epilepticus on the ICU. Relevant literature was identified by a Pubmed search of epilepsy and status epilepticus in conjunction with individual anaesthetic agents.

SummaryFactors affecting the spread of bupivacaine in the paravertebral space were investigated in patients undergoing paravertebral nerve blocks for the treatment of chronically painful conditions. Injections of bupivacaine 0.5%, 10-15 ml mixed with depomedrone up to 80 mg were repeated at 2-wk intervals up to a maximum of four times. A blinded observer mapped out the subsequent distribution of sensory loss to cold on both sides of the torso at 5-min intervals after each injection. Age, sex, height and weight did not correlate with the block; nor did injectate volume, mass of bupivacaine, previous posterolateral thoractomy and spread of radiocontrast. Injections repeated at 2-wk intervals in the same patient resulted in different degrees of spread that were unrelated to one another. Time to peak onset of blockade was 40 min in 95% of patients. A single bolus of bupivacaine produces a safe but unpredictable block. Yet to be defined physical properties and anatomical factors are probably key determinants of the spread of bupivacaine in the paravertebral space. This single bolus technique may be better supplanted by a reversion to the older multiple level injection technique.Keywords Local anaesthetic. Bupivacaine: nerve block, intercostal nerve. Two aspects of paravertebral nerve blocks that have been poorly investigated are the predictability of spread of local anaesthetic and the reliability of production of the block. To identify any involved factors, we undertook this prospective, single-blinded, longitudinal, observational study of patients undergoing therapeutic paravertebral blocks as a part of their chronic pain management. MethodsThe study was approved by the local ethics committee and written informed consent was obtained from all patients.Patients listed for therapeutic paravertebral injections as a component of management of chronically painful conditions of the chest and abdomen were included in the study. Those with a pre-existing sensory deficit were excluded. A single injection technique was used, as described elsewhere [1]. All blocks were performed to the satisfaction of the same experienced operator (J.R.). Correct Tuohy needle placement alongside the vertebral column superior to the transverse process in each patient was confirmed through the injection of 3 ml of radioopaque dye (Isovist, Schering, Germany). All material was injected with the Tuohy needle opening pointing cranially and contrast medium was tracked with an image intensifier, its shape being categorised as globular or as a cranio-caudal streak. Bupivacaine 0.5%, 10-15 ml mixed with depomedrone up to 80 mg was injected over 60 s.In the recovery room, a blinded observer mapped out the subsequent distribution of sensory loss to cold on both sides of the torso at 5-min intervals until a stable block had been established, i.e. two 5-min observations were the 684Ó 2003 Blackwell Publishing Ltd same. The cold stimulus used was a mixture of ice in tap water contained in a copper test tube. Each patient also had non-invasive measurements...