There are unacceptably high pain scores in patients undergoing TKA without the use of NSAIDs. There should be focused intervention with this group of patients to improve their pain scores and reduce their length of stay.

SummaryThe cardiovascular efects ojjibrescope-guided nasotracheal intubation were compared to those o f a control group of patients who w'ere intubated using the Macintosh laryngoscope. The 60 Stimulation of the upper respiratory tract by laryngoscopy and tracheal intubation induces sympathetically-mediated tachycardia and hypertension.',? This pressor response can cause significant morbidity and mortality, and may be hazardous particularly for patients with cerebral or cardiovascular disease.'." It has been reported recently that fibreoptic orotracheal intubation under general anaesthesia produces a more severe pressor response than conventional intubation using the Macintosh Iaryngo~cope.~ Nasotracheal rather than orotracheal intubation is indicated in anaesthesia for intra-oral operations, when the presence of a transoral tube may obstruct surgical access. The cardiovascular changes appear to be minimal when fibreoptic nasal intubation is performed under local anaesthesia in awake but sedated patients.6 However, the responses to fibreoptic nasal intubation under general anaesthesia have not been investigated.There is evidence that the magnitude of the pressor response varies with the intubation technique;>' consequently, it is important to establish the cardiovascular effects of fibreoptic-assisted nasal intubation in anaesthetised patients. This study was designed to identify the heart rate and arterial pressure changes during nasal intubation effected with the fibreoptic laryngoscope and to compare them with those of nasal intubation effected with the Macintosh laryngoscope during general anaesthesia. Patients and methodsThe investigation was approved by the ethics committee of the South Birmingham Health Authority and informed written consent was obtained from each patient. Sixty fit (ASA class 1) patients aged between 16 and 48 years who required elective nasotracheal intubation for oral surgery under general anaesthesia were studied. Patients taking vasoactive drugs and those expected to present difficulty at intubation were excluded from the trial. The majority were scheduled for either the excision of impacted third molar teeth or the enucleation of maxillary cysts.Patients were premedicated orally with temazepam 20 mg, one hour before the operation. An intravenous cannula was sited and continuous ECG monitoring established in the anaesthetic room. Arterial pressure and heart rate were recorded at one-minute intervals with a Dinamap 1846 monitor and TR2000 printer. A 5-minute stabilisation period was allowed before baseline measurements were made. Anaesthesia was induced with a dose of thiopentone sufficient to obtund the eyelash reflex (usually 4-5 mg/kg over 30 seconds); then vecuronium was administered in a dose of 0.125 mg/kg. The patient's lungs were ventilated for 4 minutes with oxygen 50%, nitrous oxide 50% and isoflurane 1 % by means of a Guedel airway and a facemask attached to a Bain system with an initial fresh gas flow rate

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Hg (amlodipine) and 88 to 80 mm Hg (enalapril) (95% CI for the difference between the drugs -4.9, 7.6) after 8 weeks treatment. 5 Home blood pressure recordings confirmed these reductions in blood pressure, although there was no significant difference between treatments for the reductions in blood pressure. 6 Both drugs were reasonably well tolerated. The adverse events occurring most frequently in the amlodipine group were headache (2), peripheral oedema (5) and palpitations (2). The adverse events occurring most frequently in the enalapril group were headache (2), peripheral oedema (2), palpitations (2) and dizziness (3).