Premedication with intranasal midazolam in pediatric anesthesia

To evaluate nasally administered midazolam 0.2 mg.kg-1 for preinduction of anaesthesia in paediatric patients the authors studied ASA 1 patients scheduled for elective surgery. Forty-five children, ages 3 to 126 months, were randomized in three groups: group D (n = 16) received diazepam 0.33 mg.kg-1 orally, group P (placebo) (n = 13) 0.04 ml.kg-1 normal saline via the nasal route; in group MDZ (n = 16) the children were given intranasal midazolam 0.3 mg.kg-1. The premedication was assessed on a 5-point sedation scale, modified to include the response to mask placement and the quality of the induction of general anaesthesia. The degree of sedation, heart rate, blood pressure, respiratory rate and oxygen saturation levels were recorded on the arrival in the operating room (0 min) and 3, 6, 9, 12 and 15 min (mask placement) after drug administration. With intranasal midazolam sedation was demonstrable at 6 min and was significant at 9 and 12 min. In this group all the children were calm or drowsy. The induction of anaesthesia was equivalent in group D and MDZ but easier than in those patients receiving normal saline. Vital signs did not change during the study period in any of the three groups. Intranasal midazolam was slightly more effective than oral diazepam. In children, it produces anxiolysis and sedation with rapid onset and is an attractive alternative to other routes for preanaesthetic medication.     

Haemodynamic comparison of propofol-fentanyl anaesthesia with midazolam-fentanyl anaesthesia in CABG patients without preoperative heart failure

This study was designed to compare prebypass haemodynamics under total intravenous anaesthesia (TIVA) using midazolam-fentanyl (group M) and propofol-fentanyl (group P) combinations. Sixteen adult patients undergoing CABG were studied with patients in group M and P (n = 8 each) given intravenous midazolam 0.1 mg.kg-1.h-1 and propofol 4 mg.kg-1.h-1 with fentanyl 25 micrograms.kg-1 until sternotomy, respectively. Following induction of anaesthesia, cardiac index and heart rate decreased significantly (30% and 20% in both groups, p < 0.05) these variables returned to baseline on completion of sternotomy. In addition, in group P mean arterial pressure decreased significantly (about 15%) following induction and there were no ischaemic signs. Overall for MAP there was no significant difference between the two groups. LVSWI and RVSWI were reduced by around 25% in both groups. Only the change in LVSWI reached statistical significance (p < 0.05). This reduction may have exert a caridioprotectant action by decreasing myocardial oxygen consumption. We conclude that both TIVA techniques represent an acceptable anaesthetic regimen for use in cardiac anaesthesia.     

Endocrine response to surgery in children after premedication with midazolam or papaveretum

The effect of two premedications on the sympatho-adrenal and endocrine stress-response to minor surgery under halothane anaesthesia was investigated in 16 children. One group (n = 9) was premedicated with midazolam, 0.1 mg kg-1, and atropine 0.2-0.4 mg i.m. The other group (n = 7) received papaveretum 0.4 mg kg-1 and hyoscine 0.008 mg kg-1 i.m. Plasma concentrations of catecholamines, ACTH and cortisol were measured during undisturbed anaesthesia, during surgery and 15 min post-operatively. There were no differences in catecholamine concentrations between the groups. Prior to surgery, plasma ACTH was significantly lower (P less than 0.05) in the papaveretum group. During surgery, plasma cortisol and plasma ACTH were significantly lower after papaveretum premedication. Post-operatively there were no differences. End-tidal CO2 concentrations were similar in the two groups. It was concluded that the endocrine stress-response immediately after induction of anaesthesia and during surgery was lower after papaveretum than after midazolam premedication.     

A randomized trial of caudal block with bupivacaine 4 mg x kg-1 (1.8 ml x kg-1) plus morphine (150 microg x kg-1) vs general anaesthesia with fentanyl for cardiac surgery

BACKGROUND: Regional anaesthesia has been used effectively in paediatric patients undergoing cardiac surgery and is thought to be safe. METHODS: Thirty patients ASA physical status II-III undergoing scheduled palliative or corrective cardiac surgery, receiving premedication with midazolam and anaesthetic induction with sevoflurane, fentanyl and pancuronium were randomly allocated to two groups. In group 1, patients received bupivacaine 0.22% 4 mg.kg-1 (1.8 ml.kg-1) and morphine 150 microg x kg-1 by the caudal route. After a 20-min period for the block to take effect, sevoflurane 0.5-1.0% and fentanyl 5 microg x kg-1 were administered for maintenance of anaesthesia. In group 2, the anaesthetic technique was the same as in group 1, without a caudal block and fentanyl 25 microg x kg-1 was administered at the moment of surgical incision. RESULTS: Cardiovascular and haemodynamic responses of patients receiving caudal block showed minor variations during the 20-min period between caudal and general anaesthesia. Fentanyl requirements during surgery were lower (P = 0.001) in patients with caudal block than patients with general anaesthesia. Extubation time was shorter (P = 0.034) in the caudal group. Two patients in the general anaesthesia group and one in the caudal group died because of postoperative complications. CONCLUSIONS: Caudal block with bupivacaine 0.22% 4 mg.kg-1 (1.8 ml.kg-1) and morphine 150 microg x kg-1 was safe and effective for paediatric patients undergoing cardiac surgery. However, patients might have a better outcome with a reduction of morphine dosage and administration of a muscle relaxant of shorter duration of action than pancuronium.     

Catecholamine response to laryngoscopy and intubation

The haemodynamic response and changes in plasma catecholamine concentrations associated with laryngoscopy and tracheal intubation were compared during anaesthesia employing three strictly standardised techniques with commonly used drug combinations. Thirty-six patients were investigated consecutively resulting in 12 patients in each of three study groups. Anaesthesia was induced with thiopentone 5 mg.kg-1 (group 1), fentanyl 6 micrograms.kg-1 with thiopentone 5 mg.kg-1 (group 2), or midazolam 0.2 mg.kg-1 with fentanyl 6 micrograms.kg-1 (group 3). Undesirable changes in haemodynamic effects and an elevation of plasma catecholamine concentrations during laryngoscopy and intubation occurred in group 1. Heart rate and mean arterial pressure increased significantly (34% and 23% respectively). Noradrenaline concentration increased by a maximum of 147%. The addition of fentanyl (groups 2 and 3) attenuated the adverse haemodynamic response and elevation of plasma catecholamine concentrations; heart rate and mean arterial pressure did not differ from pre-intubation values and plasma catecholamine concentrations decreased steadily. Substitution of thiopentone by midazolam in combination with fentanyl abolished the adverse haemodynamic response and modified the increase in plasma catecholamine concentrations. 'High-dose' opioid anaesthesia is not necessary to produce optimal conditions during laryngoscopy and intubation.     

Antagonism of benzodiazepine-fentanyl anaesthesia with flumazenil

The specific benzodiazepine antagonist flumazenil (Ro 15-1788) (Ro) was given in a double-blind study to 40 adult orthopaedic patients in order to determine if it shortens the immediate recovery time after benzodiazepine-fentanyl anaesthesia. On the evening before operation the patients were premedicated orally with 1-2 mg of flunitrazepam and 30 min before the induction of anaesthesia with 7.5 mg midazolam. Induction of anaesthesia was carried out with flunitrazepam 0.03-0.04 mg.kg-1 and fentanyl 0.1 mg IV. Anaesthesia was maintained with fentanyl (5.9 microgram.kg-1.h-1) and nitrous oxide. After the reversal of muscle relaxation, 20 patients received a placebo and 20 patients Ro, as boluses up to 10 ml, until the effect of awakening was noticed. The dose of Ro (0.1 mg.ml-1) required was 6.8 +/- 2.9 micrograms.kg-1 and that of placebo 10 +/- 0 ml. Patients given Ro woke up faster than patients given placebo. Ro patients were more alert than patients given placebo until 120 min after the injection or the test drug. After this patients in both groups behaved similarly. Eight patients given Ro and one given placebo showed some mild adverse reaction for 5-60 min after the administration of Ro or placebo (e.g., nausea, shivering). This study indicates that flumazenil speeds up awakening after benzodiazepine-fentanyl anaesthesia.     

Prolonged elimination of midazolam after i. m. administration

The elimination pharmacokinetics of midazolam after i.m. administration was compared with combined i.m. and i.v. administration in a randomized study of 55 gynaecological patients in outpatient general anaesthesia. Group 1 (n = 40) received midazolam 0.1 mg/kg i.m. as premedication 45 min before induction of general anaesthesia with midazolam 0.3 mg/kg i.v. Group 2 (n = 15) received midazolam 0.1 mg/kg i.m. as premedication 45 min before induction of general anaesthesia with thiopentone 4 mg/kg. Serum midazolam concentration measurements were performed regularly post-induction for 7 h in each patient. The elimination half-life of midazolam after i.m. administration (Group 2) was 6.6 +/- 1.2 h (mean +/- s.e. mean), which was significantly longer (P less than 0.05) than the 3.9 +/- 0.3 h observed after the combined i.m. and i.v. administration of midazolam (Group 1), and significantly longer than 2.9 h obtained from a calculated i.v. administration curve. We postulate a slow i.m. depot release of midazolam, representing the rate-limiting step in the elimination of midazolam after i.m. administration.     

A comparison of remifentanil and fentanyl in patients undergoing carotid endarterectomy

BACKGROUND AND AIM: We investigated the haemodynamic stability and emergence characteristics of isoflurane/nitrous oxide anaesthesia supplemented with remifentanil or fentanyl in patients undergoing carotid endarterectomy. METHODS: Anaesthesia was induced with propofol (1-2 mg kg-1) and either remifentanil (0.5 microgram kg-1) or fentanyl (1 microgram kg-1), followed by an infusion of remifentanil (0.2 microgram kg-1 min-1) or fentanyl (2 micrograms kg-1 h-1). RESULTS: There were no significant differences between the groups in haemodynamic variables, postoperative pain, nausea or vomiting. After induction there was a significant decrease in mean arterial pressure for both groups (P < 0.001) and a decrease in heart rate (P = 0.001) in the remifentanil group. In both groups these haemodynamic changes continued during maintenance of anaesthesia (P < 0.05). The time to eye opening after surgery was significantly shorter with remifentanil compared with fentanyl (6.62 +/- 3.89 vs. 18.0 +/- 15.18 min, P = 0.015). CONCLUSION: Remifentanil appears to be a comparable opioid to fentanyl when supplementing isoflurane/nitrous oxide anaesthesia for carotid endarterectomy.     

Propofol in urological endoscopy in elderly patients. Comparison with methohexital

Twenty patients undergoing cystoscopy (group A) and forty patients undergoing transurethral resection (group B), aged more than 65 years, were anaesthetized. Duration of anaesthesia was less than 15 min for cystoscopy, and more than 30 min for transurethral resection. No premedication was given. The patients were ASA I or ASA II. Group A patients were allocated randomly to receive either 1.5 mg . kg-1 propofol (n = 10) or 2 mg . kg-1 methohexitone (n = 10) for induction of anaesthesia. Anaesthesia was maintained using incremental doses of propofol or methohexitone and 60% N2O with a face-mask. Forty group B patients undergoing transurethral resection were randomly assigned to four equal groups (PB: propofol 1.5 mg . kg-1; MB: methohexitone 2 mg . kg-1; PF: propofol and 1.5 micrograms . kg-1 fentanyl; PFV: propofol, 2 micrograms . kg-1 fentanyl and 0.1 mg . kg-1 vecuronium). Suxamethonium (1 mg . kg-1; groups PB, MB and PF) and vecuronium (0.1 mg . kg-1; group PFV) were given to facilitate endotracheal intubation. Anaesthesia was maintained by infusion of propofol or methohexitone, using a calibrated pump started immediately after intubation. Ventilation was controlled only in group PFV. Induction with 1.5 mg . kg-1 propofol resulted in stopping counting after 62 s and loss of the eye-lash reflex after 84 s versus 47 and 67 s respectively with methohexitone. The anaesthesist's assessment was favourable for cystoscopy with propofol and methohexitone; recovery times were similar for the two drugs in cystoscopy lasting less than 30 min.(ABSTRACT TRUNCATED AT 250 WORDS)     

Verbessern intravenöses Fentanyl oder Midazolam vor Durchführung einer peripheren Regionalanästhesie Patientenakzeptanz und Kooperativität bei der Katheteranlage?

BACKGROUND: The procedure of placing a catheter for continuous regional anaesthesia is often associated with fear and pain in the patient. Thus, we evaluated the use of midazolam and fentanyl to improve patient's comfort and cooperation. METHODS: After an oral dose of 20 mg clorazepate, 174 patients receiving peripheral nerve catheters for regional anaesthesia where randomized into 3 groups to receive either intravenous placebo, 3 mg midazolam or 0.1 mg fentanyl immediately before catheter placement in a double-blind manner. Stepwise regression analysis was used to identify factors associated with patient's assessment of subjective discomfort (measured using a VAS 0-10) during the procedure. Amnesia was evaluated 24 h later. The anaesthetist rated patient's cooperation during catheter placement. RESULTS: Female sex and longer duration of catheter placement had significant negative impact on patient's comfort, whereas fentanyl showed an improvement. Age, body mass index, midazolam and the type of catheter had no influence. The following day 27% of the midazolam group, 6% of the placebo group and 9% of the fentanyl patients did not remember catheter placement. Patient's cooperation was poor in 26% of the midazolam patients but only in 9% of the placebo and 3% of the patients receiving fentanyl. Of the placebo patients 18.4% had to be supplemented with fentanyl because they found the procedure of catheter placement unbearable. No side effects occurred in either group. CONCLUSION: As patient's comfort and cooperation were significantly improved by fentanyl, we recommend fentanyl to facilitate catheter placement for regional anaesthesia.     

Tussive effect of a fentanyl bolus

The aim of this study was to investigate the incidence of pre-induction coughing, after an iv bolus of fentanyl. The study sample was 250 ASA physical status I-II patients, scheduled for various elective surgical procedures. The first 100 were randomly allocated to receive 1.5 micrograms.kg-1 fentanyl via a peripheral venous cannula (Group 1), or an equivalent volume of saline (Group 2). Twenty-eight per cent of patients who received fentanyl, but none given saline, coughed within one minute (P less than 0.0001). The second 150 patients were then randomly assigned to three equal pretreatment groups. Group 3 received 0.01 mg.kg-1 atropine iv one minute before fentanyl. Groups 4 and 5 received 0.2 mg.kg-1 morphine im, and 7.5 mg midazolam po, respectively, one hour before fentanyl. Thirty per cent of patients in Group 3, 6% in Group 4, and 40% in Group 5, had a cough response to fentanyl. Fentanyl, when given through a peripheral cannula, provoked cough in a considerable proportion of patients. This was not altered by premedication with atropine or midazolam, but was reduced after morphine (P less than 0.01). Coughing upon induction of anaesthesia is undesirable in some patients, and stimulation of cough by fentanyl in unpremedicated patients may be of clinical importance.     

A comparison of fentanyl,esmolol, and their combination for blunting the haemodynamic responses during rapid-sequence induction

The purpose of this randomized, double-blind study was to compare the ability of a combination of fentanyl and esmolol to blunt the haemodynamic effects of intubation with that of either agent alone. Patients received fentanyl or saline four minutes before, and esmolol or saline two minutes before rapid-sequence induction of anaesthesia. The F2 group (n = 24) received fentanyl 2 micrograms.kg-1, the E2 group (n = 24) received esmolol 2 mg.kg-1, the F2/E2 group (n = 25) received a combination of fentanyl 2 micrograms.kg-1 and esmolol 2 mg.kg-1, and the F5 group (n = 26) received fentanyl 5 micrograms.kg-1. Following tracheal intubation, the maximum percent change from baseline heart rate was less in the F2/E2 and F5 groups (12% and 16% respectively) than in the E2 group (34%)(P < 0.05). The maximum percent changes from baseline systolic blood pressure in the F2/E2 and F5 groups (15% and 6% respectively) were less than in the F2 and E2 groups (24% and 33% respectively) (P < 0.05). The combination of a low dose of fentanyl and esmolol provides an alternative to a higher dose of fentanyl for blunting the haemodynamic responses to laryngoscopy and tracheal intubation during rapid-sequence induction in healthy patients.     

Evaluation of the electroencephalographic bispectral index during fentanyl-midazolam anaesthesia for cardiac surgery. Does it predict haemodynamic responses during endotracheal intubation and sternotomy?

The bispectral index, a value derived from the electroencephalogram, has been proposed as a measure of anaesthetic effect. The aim of the present study was to evaluate the bispectral index during midazolam-fentanyl anaesthesia for cardiac surgery for its possible role as a predictor of increases in systolic blood pressure during endotracheal intubation and sternotomy. After institutional approval 15 consenting patients, scheduled for elective cardiac surgery, were selected for the study. Anaesthesia was induced in all patients with a loading dose of fentanyl 7.5-10 micrograms kg-1, midazolam 0.15 mg kg-1 and pancuronium 0.1 mg kg-1. After a further bolus dose of fentanyl 10-12.5 micrograms kg-1 prior to the start of incision and sternotomy, maintenance infusion rates of fentanyl 4-6 micrograms kg-1 h-1 and midazolam 0.1 mg kg-1 h-1 were started and continued through surgery at the discretion of the anaesthetist and guided by the presenting clinical and haemodynamic responses. The control of anaesthesia was never based on the value of the bispectral index. The mean bispectral index value decreased from 95.7 (3.1) at base-line to 59.5 (12.0) after induction of anaesthesia and then remained below 70 throughout surgery. However, there was an important interindividual variability in bispectral index values despite standardized dosages of fentanyl and midazolam. There was no significant correlation between the bispectral index values in the pre-intubation and pre-incision period and the changes in systolic blood pressure during endotracheal intubation and sternotomy, respectively. In conclusion, the large intersubject variability in the bispectral index values should be investigated further in the light of the great variability in the clinical effects of midazolam and fentanyl. The lack of significant correlation between the bispectral index values and the haemodynamic responses suggest that the bispectral index, which is a helpful monitor of anaesthetic depth, is not a very reliable monitor of global anaesthetic adequacy during total intravenous anaesthesia with a combination of midazolam and fentanyl in cardiac surgical patients.     

The pharmacokinetics of midazolam in various kinds of anesthesia

Several authors reported a decrease in metabolism of drugs during inhalational anesthesia. In this study we investigated the influence of several kinds of anesthesia on the metabolism of midazolam. Methods. In 43 patients who underwent minor surgery, anesthesia was induced by injecting 0.2 mg fentanyl followed by 0.15 mg/kg midazolam. Anesthesia was maintained by either halothane/nitrous oxide (group 1), isoflurane/nitrous oxide (group 2), fentanyl/droperidol/nitrous oxide (group 3), or halothane/air/oxygen (group 4). Venous blood was drawn after 5, 15, 30, 60, 90, 120, 180, 240, 300 and 360 min. Using the two-compartment model we estimated distribution half-life (t1/2a), elimination half-life (t1/2el), clearance (Cl), and volumes of distribution (Vz = volume in elimination phase). Results. There were no significant differences of elimination parameters between the four groups. Elimination half-life ranged from 0.72 to 15.06 h. Cl ranged from 2.5 to 12.8 ml/min per kilogram. Four patients (= 9%) had a t1/2el of 7-15 h; in 16 cases we found secondary concentration peaks. There was no correlation between drowsiness in the postoperative period and midazolam concentration. Conclusion. Even if anesthesia should influence the metabolism of midazolam, for example by reducing liver blood flow, we did not find any difference between the four groups. In accordance with others, we found some patients with a half-life of up to 15 h, which might reflect the influence of the anesthesia itself.(ABSTRACT TRUNCATED AT 250 WORDS)     

IV perioperative ketoprofen in small children during adenoidectomy

We have investigated the analgesic and opioid sparing effect of perioperative i.v. ketoprofen in a randomized, double-blind, placebo- controlled, parallel group study in 164 children, aged 1-7 yr, after adenoidectomy. A standard anaesthetic method was used and all children received fentanyl 1 microgram kg-1 i.v. during induction. Children in the ketoprofen group received ketoprofen 1 mg kg-1 i.v. after induction of anaesthesia followed by an infusion of ketoprofen 1 mg kg-1 over 2 h. Children in the placebo group received 0.9% saline. All children received fentanyl 1 microgram kg-1 i.v. as rescue analgesia. In the ketoprofen group less children required postoperative fentanyl (64% vs 77%, P = 0.006) and the total number of fentanyl doses was smaller compared with the placebo group (mean 1.0 (SD 1.1) (95% confidence intervals (CI) 0.8-1.3) vs 1.5 (1.1) (95% CI 1.2-1.7), P = 0.012). Worst pain observed in the postanaesthesia care unit was also lower in the ketoprofen group both at rest (P = 0.028) and during swallowing (P = 0.001). There were no difference in the number of adverse reactions between the groups. No serious adverse reactions occurred.      

A combination of fentanyl-midazolam-propofol provides better intubating conditions than fentanyl-lignocaine-propofol in the absence of neuromuscular blocking agents

BACKGROUND: The use of propofol and adjuvants such as opioids, benzodiazepines and local anaesthetic agents, may provide adequate conditions for tracheal intubation without the need for neuromuscular blocking agents. In this randomized, double-blind study, intubating conditions after induction of anaesthesia with propofol, midazolam and fentanyl were compared with those after propofol, lignocaine and fentanyl. METHODS: In 80 ASA I/II adult patients undergoing elective gynaecological surgery, intubating conditions were compared after induction of anaesthesia with a fentanyl 2 microg/kg, midazolam 0.03 mg/kg, propofol 2.5 mg/kg combination (group FMP) vs. a fentanyl 2 microg/kg, lignocaine 1.5 mg/kg, propofol 2.5 mg/kg combination (group FLP). Intubating conditions were assessed using a qualitative scoring system. RESULTS: Intubation was successful in all patients in group FMP and in 87.5% of patients in group FLP; (P= 0.021). Overall, intubating conditions were clinically acceptable in 77.5% and 55% of patients in group FMP and group FLP, respectively (P= 0.033). CONCLUSION: We conclude that the fentanyl, midazolam, propofol combination more reliably provides acceptable conditions for intubation than the fentanyl, lignocaine, propofol combination. Intubation was successful in all patients receiving the fentanyl, midazolam, propofol combination.     

Small doses of remifentanil or sufentanil for blunting cardiovascular changes induced by tracheal intubation: a double-blind comparison

BACKGROUND AND OBJECTIVE: To compare the effects on cardiovascular changes induced by tracheal intubation when small doses of either remifentanil or sufentanil are used in the presence of midazolam. METHODS: Thirty normotensive, ASA physical status I-II patients, receiving general anaesthesia for major abdominal surgery, received an intravenous midazolam premedication (0.05 mg kg-1) 10 min before induction. They were randomly allocated to receive in a double-blind fashion an intravenous bolus of either (a) remifentanil given as a bolus dose 1 microgram kg-1 (n = 15), or else (b) sufentanil 0.1 microgram kg-1 infused over 60 s (n = 15). In each instance this loading dose was followed by a continuous intravenous infusion (0.1 microgram kg-1 min-1 or 0.01 microgram kg-1 min-1 of remifentanil or sufentanil, respectively). General anaesthesia was induced with propofol (2 mg kg-1), followed by atracurium besilate (0.5 mg kg-1) to facilitate tracheal intubation. Following intubation, the lungs were mechanically ventilated with a 60% nitrous oxide in oxygen mixture and a 1% inspired sevoflurane. RESULTS: Arterial pressure and heart rate were recorded before induction of anaesthesia (baseline), immediately before intubation, immediately after tracheal intubation and every minute for the first five minutes thereafter. No differences in systolic and diastolic arterial pressures were observed between the two groups. At the end of the study period, systolic and diastolic pressures slightly decreased from preinduction values in both groups. Four patients in the remifentanil group (26%) and five patients in sufentanil group (33%) showed at least one systolic pressure value < 90 mmHg during the study period (P = not significant); however, the observed decreases in systolic pressure were transient and did not require treatment. Heart rate values were not affected by tracheal intubation in either group. CONCLUSIONS: In healthy normotensive patients without cardiovascular disease the use of a relatively small dose of either remifentanil or sufentanil after standard midazolam premedication results in a similar and clinically acceptable effectiveness in blunting the cardiovascular changes induced by tracheal intubation.     

Chest wall rigidity during fentanyl– and midazolam–fentanyl induction: ventilatory and haemodynamic effects

In a double-blind randomised study, we examined if pretreatment with small doses of midazolam, given before anaesthesia induction with fentanyl, influences the occurrence of fentanyl-induced thoracic rigidity (FITR). At the same time, the effect of rigidity on the cardiovascular and respiratory system was assessed. Sixteen patients undergoing coronary artery bypass surgery were divided into two groups. The midazolam group (M) received 0.075 mg/kg midazolam i.v. and the placebo group (P) NaCl 0.9% 3 min before the start of fentanyl induction. During the induction period, FITR was assessed clinically on a 3-point scale. Haemodynamic and respiratory variables were collected before anaesthesia induction, at the end of the fentanyl infusion and 3 min after intubation. The incidence of FITR was high in both groups: 63% in Group M and 75% in Group P (n.s.); however, its severity was less in Group M. The appearance of rigidity affected the cardiovascular and the respiratory system: central venous and pulmonary capillary wedge pressures showed a sharp increase in patients with FITR accompanied by CO2 retention, due to an inability to ventilate these patients adequately. We conclude that small doses of midazolam do not prevent, but may attenuate, FITR and that the appearance of rigidity causes alterations of haemodynamic and respiratory variables during induction.     

Effect of rocuronium compared with succinylcholine on intraocular pressure during rapid sequence induction of anaesthesia

We have compared the effect of rocuronium and succinylcholine on intraocular pressure (IOP) during rapid sequence induction of anaesthesia using propofol and fentanyl, in a randomized double-blind study. We studied 30 adult patients, allocated to one of two groups. Anaesthesia was induced with fentanyl 2 micrograms kg-1 and propofol until loss of verbal response. This was followed by succinylcholine 1.5 mg kg-1 (group S; n = 15) or rocuronium 0.9 mg kg-1 (group R; n = 15). Laryngoscopy was performed 60 s later. IOP, mean arterial pressure (MAP) and heart rate (HR) were measured before induction, immediately before intubation and every minute after intubation for 5 min. A Keeler Pulsair air impulse tonometer was used to measure IOP and the mean of two readings obtained in the right eye at each measurement time was recorded. Intubating conditions were evaluated according to a simple scoring system. IOP in the succinylcholine group was significantly greater than that in the rocuronium group (mean 21.6 (SEM 1.4) mm Hg vs 13.3 (1.4) mm Hg; P < 0.001). Intubating conditions were equally good in both groups. We conclude that with rapid sequence induction of anaesthesia using propofol and fentanyl, rocuronium did not cause as great an increase in IOP as succinylcholine and may be an alternative in open eye injury cases.      

Ambulatory anesthesia and induced abortion. Comparative study of propofol-alfentanyl and ketamine-midazolam combinations

The use of propofol alone or with alfentanil in the day-case anaesthesia for abortion was compared with that of ketamine with midazolam. Two hundred young women were assigned to two successive series of two groups each. The four groups were: group 1 (2 mg . kg-1 propofol only); group II (0.5 mg . kg-1 ketamine with 0.25 mg . kg-1 midazolam); group III (2 mg . kg-1 propofol with 4 micrograms . kg-1 alfentanil); group IV (1 mg . kg-1 ketamine with 0.1 mg . kg-1 midazolam). All the patients were premedicated one hour before anaesthesia with 0.25 mg . kg-1 midazolam orally. All the patients were asleep at the end of the propofol injection (60 s), and 10 to 15 s later for the ketamine-midazolam groups. The haemodynamic parameters did not vary much during induction with ketamine-midazolam. In the propofol groups, the heart rate remained steady, with an 8 to 12% fall in blood pressure. A fall of the mandible was seen in 40 and 84% of the patients in the propofol groups, with a short apnoea in 32 and 48% of these same patients. Clinical recovery was very quick, less than 12 min for all groups. The four psychomotor and sensory tests were carried out at the 30th min by 95% of the patients in the propofol groups, whereas only 50% of those in the ketamine-midazolam groups did so. Speed and quality were significantly better in the propofol groups. The most frequent adverse effect of propofol was pain during injection in 32 and 14% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)