In anaesthetized dogs, stellate ganglion blockade led to a moderate disturbance in left ventricular diastolic function. We investigated the effect of a left-sided block, following injection of 10 mL bupivacaine 0.5%, on echocardiographic variables of ventricular function in eight otherwise healthy patients with sympathetically mediated pain syndromes. After the blockade, heart rate (control: 66±3 (mean± SEM), block: 64± 3 min−1) and mean arterial blood pressure (88.5±6.0 vs. 84.0±8.1 mmHg) were unchanged, but afterload decreased (end-systolic meridional wall stress; 69.6±9.9 vs. 59.8±7.1, P<0.05). Stroke volume increased from 71.2±8.1 to 79.6±7.4 mL, P <0.05. Variables of systolic function were unchanged, but relaxation was prolonged (isovolumic relaxation time; 71±5 vs. 81±4 ms, P<0.05). In patients who were ASA I, there was a small impairment in echocardiographic variables during ventricular relaxation after a left stellate ganglion blockade. This small effect did not compromise ventricular function, and the heart responded with a small stroke volume increase to the simultaneous afterload reduction.

Although nonopiate analgesics may be particularly useful in the immediate postoperative period after major surgery, their use has been associated with haemodynamic adverse effects during postoperative pain treatment and in critically ill patients in intensive care. The effect of a single intravenous dose of metamizol (dipyrone) 2g, ketorolac 30mg and propacetamol 1g on haemodynamic variables and pain control in the immediate postoperative period after heart surgery is compared. Seventy-two patients undergoing elective coronary and/or heart valve surgery, were included in a cohort study of 1-years duration (1998). After weaning from mechanical ventilation and extubation, haemodynamic variables and a 4-point verbal rating pain scale were asseseed at base-line and 60 min after the administration of a single doses of metamizol, ketorolac or propacetamol. The Student's t-test for paired samples was used to compare changes produced by the study medications. A significant, but small, decrease in radial artery blood pressure was observed in all treatment groups which had little clinical relevance; no vasodilator effects were observed and ventricular function showed only minor changes: propacetamol decreased cardiac index by 10% and a 15% decrease in right ventricular work was also observed. Metamizol and ketorolac produced a 10% decrease in the left ventricular work index. Pain scores showed a statistically significant decrease in all treatment groups. The analgesic effects of metamizol, ketorolac and propacetamol were not associated with a clinically significant impairment in haemodynamic function when administered to haemodynamically stable patients.

The Royal College of Anaesthetist requires that trainees wishing to specialise in Anaesthesia register with the College and keep a logbook documenting their experience and training in clinical anaesthesia. There are a number of advantages if such logbooks are kept in an electronic format. For the first time in the United Kingdom, we have evaluated the usefulness in a district general hospital of introducing a computerized system of record keeping based on a portable palm top computer. This has enabled the careful analysis of the individual work load of each trainee in the department by means of a specific program designed to generate a comprehensive report after the information from each individual has been downloaded on to a standard desk top computer. We have found a number of interesting and unexpected results and have highlighted ways in which the system may be improved.

We examined the relation between chronic glycaemic control (using glycosylated haemoglobin), haemodynamic autonomic function and rate of gastric emptying in 16 patients with type 1 diabetes mellitus. Gastric emptying was measured using a paracetamol absorption technique. Parameters of gastric emptying include area under the plasma paracetamol concentration time curve. Patients were classified as diabetic autonomic neuropathy positive or negative using five standardized haemodynamic reflex tests. Area under the plasma paracetamol concentration time curve in the neuropathy positive (10.36 (4.5) mmol−1 min) and negative (9.84 (3.0) mmol−1 min) groups were similar (P=0.42) using unpaired Student's t-tests. Glycosylated haemoglobin concentration and area under the plasma paracetamol concentration time curve (n=16) demonstrated a Pearson's correlation co-efficient of 0.24. Neither tests of haemodynamic autonomic function, nor concentration of glycosylated haemoglobin, are predictive of diabetic gastroparesis.

We investigated the influence of intravenous clonidine 2, 4 and 6 μg kg−1 on the electroencephalogram and on the minimal alveolar concentration of isoflurane in 40 patients aged 20–60 years undergoing elective surgery. Minimal alveolar concentration was determined using the Dixon ‘up-and-down’ method. Thirty min after the clonidine infusion anaesthesia was induced with etomidate, 0.25 mg kg−1. Skin incision was made after stable end-tidal isoflurane concentrations had been maintained for at least 15 min. Clonidine caused significant decreases in the spectral edge (95%) and median power frequency of the electroencephalogram and in the bispectral index. The minimal alveolar concentration of isoflurane decreased in a dose-dependent manner from 1.32% (95% CI, 1.28%–1.36%) in the control group to 1.03% (0.9%–1.18%) in patients given clonidine 6 μg kg−1. Clonidine 4 and 6 μg kg−1 was associated with a moderate reduction in heart rate and arterial systolic blood pressure. We recommend the use of clonidine intravenously as an adjunct to general anaesthesia in a dose of 4 μg kg−1 given 15 min before induction of anaesthesia.

We have used a remifentanil-based anaesthetic for patients undergoing major abdominal surgery who would normally have gone to the intensive care unit in this hospital. Avoiding intensive care unit admission was considered an advantage as a shortage of intensive care unit beds was leading to the cancellation of operations. We first used remifentanil as part of a safety and efficacy study. The aim was to see if the rapid and complete awakening obtained when using this drug would allow us to avoid the need for admission to an intensive care unit and use a high dependency unit instead. This was shown to be practicable. In comparison with a group of patients matched retrospectively for the type of operation before remifentanil was used there was a reduction in the length of time (mean ± SD) patients’ lungs were ventilated (612 ± 417 vs. 9.9 ± 28.9 min P<0.0001). There was no saving in cost (£808.71±£187.06 vs. £795.27±£253.49). When remifentanil was used routinely (after the safety and efficacy study), there were significant reductions in the time to tracheal extubation (612±417 vs. 4±10 min P <0.0001) and costs (808.71I vs. 392.10 I P <0.0001) compared with other patients in whom it was not used. Patients waiting for a liver transplant were also being cancelled when a donor organ became available because of the shortage of intensive care unit beds. Based on our other experience with remifentanil, we used a similar anaesthetic technique for these patients. It proved possible to extubate the trachea in 12 of 15 patients at the end of the operation. No patient needed re-intubation. The need for intensive care and therefore cancellation of surgery was reduced. In contrast, only one patient's trachea was extubated immediately after surgery in the group of patients anaesthetized before the introduction of remifentanil. A remifentanil-based technique in combination with a change in organization has therefore enabled us to avoid admission to the intensive care unit for these patients.

We describe the proximal cranial needle approach for brachial plexus blockade; clear surface markings and cranial direction of the needle lead to satisfactory results with a low incidence of complications.

We investigated the effect of a small dose of midazolam, ketamine, droperidol or lidocaine on the propofol dose required for hypnosis during induction of general anaesthesia. These drugs were randomly administered to 100 patients about to undergo scheduled surgery. Propofol was then infused at a rate of 250 μg kg−1 min−1 and the hypnotic dose to produce hypnosis was evaluated. Midazolam (20 μg kg−1) and droperidol (20 μg kg−1) significantly reduced the mean hypnotic dose of propofol (mean) S.D.) compared with the placebo (43.7 ± 17.8 mg, 61.9 ± 10.6 mg and 72.5 ± 27.7 mg after pretreatment with midazolam, droperidol and placebo, respectively), whereas ketamine (0.1 mg kg−1) and lidocaine (1 mg kg−1) did not significantly affect the hypnotic dose of propofol (63.1 ± 25.6 mg and 65.1 ± 24.8 mg, respectively). Only midazolam when compared with saline administration, (176 ± 66s and 298 ± 126s, respectively), shortened the time to achieve hypnosis. The changes in blood pressure (non-invasive) and heart rate were not significantly different in all groups during the induction of anaesthesia and oro-tracheal intubation. These results raise the possibility that new combinations of central nervous system drugs, such as droperidol and propofol, have a potential to reduce the dose of intravenous anaesthetics, including propofol, that produce hypnosis without significant adverse effects.

Epinephrine lowers the serum potassium level through an effect on the β2-receptor. It is therefore difficult to evaluate whether depression of the ST level and the T wave on the electrocardiogram, during regional anaesthesia, is caused by a high plasma epinephrine level, a low serum potassium level, or both. For this purpose, we studied the relation between electrocardiogram and the plasma epinephrine and serum potassium concentrations during 20 intra-abdominal operations performed under combined epidural and general anaesthesia and in 18 subjects receiving intercostal nerve blockade. The results show that the hypokalaemic effect of epinephrine was reduced when the plasma epinephrine concentration exceeded 3 nmol L−1. A multiple regression analysis demonstrated that the ST level and the T-wave amplitude were most consistently affected by a low serum potassium level, while a high plasma epinephrine level correlated only to a depression in the T-wave amplitude. During surgery, only serum potassium correlated with these ECG variables.

To compare ease of maintenance and recovery characteristics of sevoflurane and propofol plus fentanyl in day-care anaesthesia, 60 outpatients undergoing elective surgery of up to 3 h duration were randomized to receive sevoflurane or propofol as their primary anaesthetic. Induction was always carried out with propofol, but a fentanyl bolus 5 μg kg−1 was added in the propofol group. Anaesthesia was supplemented with up to 70% N2O. Significantly shorter times to extubation (10.03 min ± 3.2 SD vs. 17.2 ± 7.3; P<0.001) and emergence (10.4 ± 3.1 vs. 16.8 ± 6.4; P<0.001) were observed in the sevoflurane group. Patients treated with sevoflurane felt less confused, showed better performances in the digit symbol substitution test and achieved higher modified Aldrete scores sooner in the post-operative course. Maintenance of anaesthesia with sevoflurane produces faster emergence and recovery than propofol plus fentanyl after anaesthesia of short to intermediate duration.