The purpose of this prospective study was to identify the incidence of a distinct central anticholinergic syndrome following routine anaesthesia. For 2 months, all inpatients aged more than 15 years scheduled for elective procedures and cared for in the recovery room were investigated for symptoms of the syndrome. Patients with neuropsychiatric disease or other disorders that could alter consciousness were excluded. Prolonged action of anaesthetics or relaxants, respiratory depression and metabolic disorder were ruled out before making the diagnosis. Out of 962 patients (366 men, 596 women), 18 (4 men, 14 women) developed the syndrome. The difference between men and women was not statistically significant. Six out of 60 women developed the syndrome after a hysterectomy with or without adnectomy/oophorectomy, and this high incidence was significantly different from that observed after all other procedures in women (P = 0.003) or all other gynaecological procedures (P = 0.013). The reason for this is unknown. In six of the 18 cases, untreated prolonged somnolence lasted for more than 2 h. All patients woke up after an injection of physostigmine, but six of them relapsed into somnolence and needed a second, and in one case a third, injection. The findings of the study emorders phasize that, when there is delayed recovery from anaesthesia, the diagnosis of central anticholinergic syndrome should be considered if other accessible causes for that condition have been excluded.

The authors compared the acceptance and efficacy of rectal and nasal administration of midazolam (MDZ) for premedication. Ninety-five ASA I and II paediatric patients (8 months to 12 years) scheduled for elective surgery were randomly allocated to two groups. Group R received 0.3 mg kg−1 of rectal midazolam (in 5mL saline). Group N received 0.2 mg kg−1 of nasal midazolam (5 mg ml−1). Both groups were divided in two subgroups according to age (group RA ( ≤ 6 years, n = 33), group RB ( > 6 years, n = 18), group NA ( ≤ 6 years, n = 28), group NB ( > 6 years, n = 16)). At the time of premedication, tolerance to the administration was confirmed. Twenty min after rectal or 10 min after nasal administration the quality of sedation was recorded. The nasal midazolam, in commonly used dosages, induced a sedation similar to that following rectal administration with a shorter delay of onset. Nasal administration was more often painful than rectal administration. Swallowing (nasal midazolam) and concerns about modesty (rectal midazolam) were more frequent in older children. Because of its poor tolerance, nasal premedication should be reversed for cases where there is no alternative. Rectal premedication should be avoided in older children.

We have used eltanolone and propofol to induce anaesthesia and by intermittent injection to supplement nitrous oxide during maintenance in 67 patients undergoing minor gynaecological surgery. This study was a controlled randomized phase III with two parallel groups and a blinded assessment of post-operative recovery. Complications during induction and maintenance were few. Urticaria occurred in two patients given eltanolone and in none of those given propofol. Time to orientation and time to eye opening were significantly shorter in the propofol group (P < 0.001). Systolic and diastolic blood pressure decreased in both groups but the decrease was significantly greater in the propofol group (P < 0.005 systolic blood pressure; P < 0.001 diastolic blood pressure). Heart rate decreased significantly in the propofol group (P < 0.002). We conclude that eltanolone anaesthesia is associated with a greater haemodynamic stability than propofol anaesthesia but that early recovery occurs more slowly.

In this study the antiemetic effects of droperidol, ondansetron and their combination were evaluated in 160 ASA Grade I and II children undergoing surgery for strabismus, who were randomly assigned to one of four groups: Group D received droperidol 75 μg kg−1, group O ondansetron 0.1 mg kg−1, group D + O received both droperidol 75 μg kg−1 and ondansetron 0.1 mg kg−1, and group N NaCl as placebo. Emesis within the first 24 h occurred in 95.0% of the children with placebo medication, compared with 32.5% (D), 40.0% (O) and 45.0% (D + O) in the groups with antiemetic prophylaxis. The differences between group N and all other groups were significant (P < 0.001). However, there were no statistically significant differences between the groups D, O and D + O. It is concluded that droperidol (75 μg kg−1) and ondansetron (0.1 mg kg−1) both significantly reduce PONV in children undergoing surgery for strabismus. Neither ondansetron, nor the combination D+O were superior to droperidol alone.

The microbiological contamination of 250 breathing system tubes after use in anaesthesia circle systems with reduced fresh gas flow was investigated. The lungs of 50 patients were ventilated without any filtering device between the endotracheal tube and the Y-piece. A total of 51, 49 and 100 patients, respectively, were given different types of heat and moisture exchanger with electret filters (HMEF). With no filtering device the tubing system was contaminated by micro- organisms originating from the patient's tracheal secretion in 13% of the patients. In contrast, no bacterial migration into the tubing system was detected when any of the investigated HMEF-devices were used. We therefore conclude that heat and moisture exchangers with electret filters prevent contamination of the anaesthesia breathing system with microorganisms from the patients airways.

All the anaesthetic machines in one District General Hospital were tested for faults on three occasions for both audit and re-audit using an extended checklist based on that devised by the Association of Anaesthetists of Great Britain and Ireland. Ninety completed checklists were analysed for the audit and 24 tests revealed 236 individual faults (range 1.1–64%). Sixty-five (27.5%) could have occurred on a day-to-day basis and 171 (72.5%) of the faults were non-recurring. Following introduction of COVERS (a pre-use checklist) re-audit of 102 completed checklists showed 20 tests revealing faults on 59 occasions (range 1.0–11.6%), 16 (27%) day to day and 43 (73%) non-recurring. COVERS supported by scheduled regular comprehensive checking delegated to another time and performer is recommended as the mandatory pre-use checklist.

Desflurane is a new inhalation anaesthetic with a low blood/gas solubility which should allow a fast emergence from anaesthesia. In a prospective open randomized study, desflurane was compared with isoflurane paying special attention to recovery and the quality of the post-operative period. The occurrence of pain and post-operative nausea and vomiting (PONV) was recorded during the first 20 post-operative hours. Seventy women ASA Grade I-II scheduled for elective gynaecological laparoscopic procedures were studied. Patients receiving desflurane were extubated earlier than patients receiving isoflurane, 5±1 and 9±1 min respectively (P < 0.05) and the patients anaesthetized with desflurane were able to tell their name and date on average 5 min earlier than those who had received isoflurane; however, time in the recovery room was the same for both groups of patients. Twenty-two of 35 patients receiving desflurane, and 18 of 35 receiving isoflurane required analgesia. PONV was recorded in 18 patients anaesthetized with desflurane and 12 patients anaesthetized with isoflurane. In both groups PONV was more frequently observed in patients after leaving the recovery room. PONV in the recovery room was associated with a delayed discharge, 139 vs. 114 min respectively. Desflurane seems to be an useful alternative to isoflurane for laparoscopic procedures.

The efficacy and side effects of 100 lumbar epidural treatments with low concentrations of bupivacaine (1 mg mL−1), fentanyl (2 μg mL−1) and adrenaline (2 μg mL−1) combined with rectal paracetamol were prospectively evaluated in children aged 4–14 years after femoral osteotomy. The mean treatment time was 43 h and the mean dose was 0.18 mL kg−1 h−1. Ninety-nine per cent of the children were either without pain or experienced very low pain at rest for at least 80% of the treatment time. The same was the case in 80% of children when pain evaluation was made on active movement. No cases of seizures, signs of catheter migration, hypotension or respiratory depression were observed. Sixty-three per cent of the patients experienced nausea or vomiting, but antiemetic treatment was indicated in only 11%. One epidural treatment had to be stopped in a child who did not respond to antiemetics. The incidence of pruritus was high (49%), but the symptoms were mild and limited.

In two consecutive, randomized, double-blind studies the effect of ondansetron on the time to induction of anaesthesia with propofol and, subsequently, thiopentone was assessed. In each study 40 patients received either ondansetron 8mg or placebo immediately before induction of anaesthesia with a standardized dose of propofol (2.5 mg kg−1) or thiopentone (5 mg kg−1). Times to induction of anaesthesia were determined by assessing loss of verbal response, motor power and eyelash reflex. There was no difference in either study in times to induction of anaesthesia between immediate pre-treatment with ondansetron or placebo. Side effects were minor and of similar incidence in the ondansetron and placebo groups.

The analgesic efficacy of tenoxicam, a newer injectable non-steroidal anti-inflammatory drug, for post-operative analgesia after abdominal or orthopaedic surgery in ASA Grade I/II patients is reported. Two hundred and fifty-six patients received a single dose of tenoxicam 40 mg intravenous (i.v.) at the end of surgery and this was repeated 24 h later. These patients were compared, with respect to pain or adverse events, with 258 patients that received placebo. All patients were monitored for the next 72 h. Overall, tenoxicam provided reliable analgesia with comparable pain scores at rest, moving and coughing. The cumulative rescue PCA-morphine consumption was always lower in the tenoxicam treated patients and was most marked at 4 and 24 h after the second injection of tenoxicam. This effect was more pronounced after abdominal surgery. The intravenous administration of tenoxicam was associated with a low incidence of adverse events and a high tolerability.

This present study investigated the effects of intraarticular morphine administration in 1mg and 5mg doses on post-operative pain relief and analgesic requirements for patients undergoing arthroscopic procedures. At the end of the operation patients were randomly allocated in a double-blinded fashion into three groups. The control group (Group 1) received normal saline 20 mL intraarticularly. The patients in the second and third groups received intraarticular morphine sulphate 1 and 5mg in saline 20 mL, respectively. Post-operative pain was assessed on the 1st, 6th and 24th hour by visual analogue scale (VSA). Supplementary analgesic requirement and possible complications were also followed. The intensity of pain and analgesic requirement were reduced more in the morphine 5mg group than in the control group. It is concluded, that the administration of intraarticular morphine 5mg provides long-lasting and effective analgesia after knee arthroscopy.

Total intravenous anaesthesia (TIVA) using propofol, gamma-hydroxybutyrate (GHB) or midazolam in combination with sufentanil was investigated in 45 patients undergoing coronary artery bypass grafting (CABG). Anaesthesia was induced with sufentanil, etomidate and pancuronium. After endotracheal intubation, anaesthesia was continued with sufentanil (2 μg kg−1 h−1) for all patients. Patients were randomized to receive supplementary propofol (2 mg kg−1 h−1, n = 15), gamma-hydroxybutyrate (20 mg kg−1 h−1, n = 15) or midazolam (0.06 mg kg−1 h−1, n = 15). Haemodynamic measurements were performed after induction and at various times in the pre-bypass period. In the propofol group, a significant decrease in heart rate (HR 12%±3%), cardiac index (CI 23%±4%), mean arterial pressure (MAP 16%±3%) and left ventricular stroke work index (LVSWI 17%±4%) occurred until sternotomy was performed. With the exception of cardiac index, both midazolam and gamma-hydroxybutyrate produced similar haemodynamic effects: cardiac index was temporarily decreased (19%±4%) by midazolam and remained unchanged after gamma-hydroxybutyrate. In both groups, sternotomy was followed by temporary hypertension, associated with a significant rise in systemic vascular resistance. No electrocardiographical signs of ischaemia were observed in any patient. In the case of propofol and midazolam, gamma-hydroxybutyrate showed adequate haemodynamic stability especially after induction of anaesthesia and may also be a suitable agent for total intravenous anaesthesia in patients with coronary artery disease. However, during sternotomy, supplementary administration of opioids was required.

A double-blind and randomized study design was used to investigate 100 healthy children, aged 1–5 years. Intubating conditions and cardiovascular changes duraning deep halothane anaesthesia, defined as an endtidal concentration of 2%, were compared with those changes during 1% halothane and suxamethonium relaxation. Intubating conditions were graded according to the ease of laryngoscopy, vocal cord position, coughing and jaw relaxation. In each group 96% of the children demonstrated acceptable intubating conditions. Jaw relaxation was worse in the 1% halothane/-suxamethonium group (P < 0.01). When anaesthesia with 2% or 1% halothane was compared there was a more pronounced decrease in systolic blood pressure (18 vs. 8%, (P < 0.001). Junctional rhythm occured more frequently during deep halothane anaesthesia (46 vs.18%, (P < 0.01). Intravenously (i.v.) administered atropine attenuated blood pressure depression significantly and reinstituted sinus rhythm in most cases.

This study was designed to investigate the incidence of critical events in breathing following light general anaesthesia compared with normal sleep during the first 12 h after transfer from the recovery room. There were no significant differences in the incidence of apnoea or desaturation episodes between normal sleep and the post-operative recovery period. There was a close correlation between the pre-operative and post-operative incidence of apnoea (r = 0.93), pre-operative and post-operative desaturation periods (r = 0.81), pre-operative and post-operative mean SpO2 values (r = 0.54) and pre-operative and post-operative minimal SpO2 values (r = 0.90) in all the patients. In the early post operative period, breathing patterns and oxygenation were similar to those observed during normal night-time sleep in elderly patients under going ophthalmological surgery.

Remifentanil is an ultrashort acting mu opioid, well suited to total intravenous (i.v.) anaesthesia. Pain immediately following emergence from anaesthesia is a potential problem because of the rapid offset. This study investigated the transition from remifentanil/propofol total intravenous anaesthesia to post-operative analgesia with epidural or patient controlled analgesia morphine in 22 patients undergoing major abdominal surgery. A remifentanil post-operative infusion initiated during emergence was titrated in the recovery room for 30 min, at which time 14% of patients had a pain score of 2 and 86% had pain scores of 0 or 1 (0 = no pain; 1 = mild pain; 2 = moderate pain; 3 = severe pain), at a mean infusion rate of 0.086 mug kg −1 min −1 . A smooth transition was then made to either epidural analgesia or patient controlled analgesia with morphine; pain scores were not significantly changed during the transition. Nausea occurred in 16 of the 22 patients, but only following administration of morphine. Epidural analgesia produced significantly lower pain scores on the surgical ward compared with patient controlled analgesia.

The cross-sectional area of the common carotid artery bulb was measured using a 5 MHz pulse wave Doppler probe in a patient undergoing general anaesthesia using a laryngeal mask airway (LMA). A simultaneous measurement of blood velocity was performed to allow determination of the blood flow. Following inflation of the cuff on the LMA, the cross-sectional area of the right carotid artery bulb decreased from 1.09 to 0.89 cm2, flow velocity increased 120 to 176 cm s−1 and the blood flow increased from 130.8 to 156.6 cm3 s−1. On the left the cross-sectional area decreased from 1.16 to 1.13 cm2, the velocity increased 136 to 151 cm s−1 and the blood flow increased from 157·8 to 170·6 cm3 s−1 . While a reduction in cross-sectional area was observed in the carotid bulb in this patient, this was accompanied by an increase in the velocity and a consequent increase in blood flow. In patients with atheromatous disease involving the carotid arteries this decrease in cross-sectional area may prove clinically significant. The use of the LMA may not be suitable for this population.

Combined effects of prolonged prostaglandin E1 (PGE1)-induced hypotension and haemodilution on hepatic function were studied in 30 patients undergoing hip surgery. The patients were randomly allocated to one of three groups; those in group A (n = 10) were subjected to controlled hypotension alone, those in group B (n = 10) to haemodilution alone and those in group C (n = 10) to both controlled hypotension and haemodilution. Haemodilution in groups B and C was produced by withdrawing approximately 1000 mL of blood and replacing it with the same amount of dextran solution, and final haematocrit values were 21 or 22%. Controlled hypotension in groups A and C was induced with PGE1 to maintain mean arterial blood pressure at 55mmHg for 180 min. Measurements included arterial ketone body ratio (AKBR, aceto-acetate/3-hydroxybutyrate) and clinical hepatic function parameters. AKBR and biological hepatic function tests showed no change throughout the time course in groups A and B. In group C, AKBR showed a significant decrease at 120 min (−40%) and at 180 min (−49%) after the start of hypotension and at 60 min (−32%) after recovery of normotension, and SGOT, SGPT, LDH and total bilirubin showed significant increases after operation. The results suggest that a prolonged combination of more than 120 min of PGE1-induced hypotension and moderate haemodilution would cause impairment of hepatic function.

Fourteen patients who underwent Charnley or Howse total hip replacement using CMW bone cement were studied. Mean values of C4 and C3 determined before the induction of anaesthesia and insertion of bone cement and also after this procedure showed no significant difference and were within the normal range. Furthermore, no evidence of C3 breakdown products was found. It was therefore concluded that neither the general anaesthetic technique nor the insertion of bone cement activated the classical or alternative complement pathways and such a mechanism was not responsible for the hypotension which occurred shortly after the insertion of bone cement in 10 cases studied.

In this case report an unusual complication is described following insertion of a Swan Ganz catheter. A 79-year-old male patient experienced knotting of the catheter. Methods of avoiding this problem and removal of a knotted catheter are discussed.

In a prospective study, experiences with peri-operative thoracic epidural analgesia (TEA) for thoracic surgery were documented. Two hundred and seven patients scheduled for elective thoracotomy were investigated. All patients received thoracic epidural catheters 2 h pre-operatively. The catheters were inserted between T4–5 and T8–9 intervertebral spaces. Epidural medication with bupivacaine and fentanyl was started pre-operatively, maintained throughout surgery and was continued post-operatively via patient controlled analgesia (PCA) devices. Patients were anaesthetized with propofol and tracheal intubation was performed following neuromuscular blockade with vecuronium. Ninety-five percent of the patients were extubated immediately after surgery. 70.5% of all the patients had excellent post-operative analgesia (VAS pain scoring 0–2) on the day of surgery, 78% the day after surgery and 91% on the second day after surgery. Additionally early post-operative mobilization could be started in 63% of all patients. No neurological sequelae caused by thoracic epidural catheterization was seen in the early post-operative period.