A CASE OF MASSIVE ASPIRATION OF GASTRIC CONTENTS DURING OBSTETRIC ANAESTHESIA: Treatment by Tracheostomy and Prolonged Intermittent Positive Pressure Ventilation

A case is described of massive aspiration of liquid gastriccontents into the lungs of an obstetric patient undergoing generalanaesthesia. Pre-operative treatment with oral alkali to neutralizegastric acid did not prevent a severe reaction in the lungs.Treatment was by general supportive measures and long-term intermittentpositive pressure ventilation via a tracheostomy. Great difficultywas experienced in ventilating the lungs because of their lowcompliance and the large physiological deadspace. Recovery wascomplicated by a severe reduction in pulmonary diffusing capacityand by the development of tracheal stenosis. The factors influencingthe treatment and complications are discussed. ^*Present addresses:United Oxford Hospitals Present addresses:Tottenham Group of Hospitals Present addresses:St. George's Hospital, London     

MASSIVE PULMONARY COLLAPSE DURING THORACOTOMY

A case is described of an incident of acute massive collapseof one lung which was seen to occur in a 28-year-old woman atoperation for mitral valvotomy. The endotracheal tube was satisfactorilyplaced and no abnormality was found on bronchoscopy. The lungslowly expanded during manual inflation with very high pressuresassisted by surgical massage of gas from the re-expanded tothe collapsed lobules. Recovery was uneventful. ^* Nottingham General Hospital, Nottingham. King's College Hospital, London (after January 1, 1967). The Mount Sinai Hospital, New York.     

THE PREVENTION OF POSTOPERATIVE VOMITING AFTER ABORTION: METOCLOPRAMIDE

The anti-emetic properties of metoclopramide were investigatedby means of a double-blind trial in patients after evacuationof the uterus following incomplete abortion. Vomiting occurredin only 6 of 50 patients who were given metoclopramide 20 mgby intramuscular injection immediately after operation, comparedwith 24 in a group of 50 in whom normal saline was injected.This difference is significant. There was a reduction in otherpostoperative side effects although all the differences werenot statistically significant. ^*Present address:St. Mary's Hospital, London W.2. Present address:University College Hospital, London W.C.I.     

EXTRADURAL METHADONE AND BUPIVACAINE IN LABOUR

We performed a double-blind placebocontrolled study of the effectsof extradural administration of methadone 5 mg or saline, followedby bupivacaine, in 42 women in early labour. Motor block andpain scores were significantly less in the methadone group.The requirement for bupivacaine also was reduced by methadone,but this was not statistically significant. There were no troublesomeside effects attributable to methadone. ^*Department of Anesthesiology, University of Maryland Schoolof Medicine, 22 South Greene Street, Baltimore, Maryland 21201,U.S.A. Anaesthetic Department, Leicester Royal Infirmary, LeicesterLE1 5WW.     

SOME PROBLEMS ENCOUNTERED IN A SEVERE CASE OF TETANUS

Tetanus in a 52-year-old woman was managed by muscle paralysisand controlled pulmonary ventilation. Marked peripheral circulatoryfailure developed and was accompanied by a fall in temperatureto subnormal levels (33.3°C) for five days. Paralytic ileusdeveloped also. She was discharged three months after enteringhospital. ^*Present addresses: Crawley Hospital, Sussex Present addresses: St.Thomas's Hospital, London     

INTERPLEURAL REGIONAL ANALGESIA: DETECTION OF THE INTERPLEURAL SPACE BY SALINE INFUSION

A saline infusion technique is described for insertion of aninterpleural catheter, to reduce the incidence of pneumothoraxduring conduct of interpleural block, especially if the blockis used as an adjunct to general anaesthesia. Presented in part at the March 1990 meeting, British Section,European Society of Regional Anaesthesia (ESRA).     

METHOXYFLURANE ANALGESIA FOR BURNS DRESSINGS: EXPERIENCE WITH THE ANALGIZER

Methoxyflurane has been used to provide analgesia for burnsdressings on sixty occasions in eleven patients. It was administeredby way of a new, disposable vaporizer, the Analgizer, whichis described. Three patients required either supplementary analgesicsor tranquillizers. No side effects were noted, and patient acceptanceof the Analgizer was good. This method is thought to representan advance over previous methods of analgesia for burns dressings,since there is no undue sedation, pre-operative starvation isunnecessary, and venepunctures are avoided. ^*This device is not yet marketed in the United Kingdom. Present address:Department of Anaesthesia, Royal HampshireCountyHospital, Romsey Road,Winchester Present address:Department of Surgery, University of Chicago,Chicago,Illinois 60637     

SEDATION FOR ENDOSCOPY: MIDAZOLAM OR DIAZEPAM AND PETHIDINE?

One hundred patients received either diazepam given with pethidine,antagonized with nalo-xone, or midazolam alone in a double-blindrandomized study of sedation for upper gastro-intestinal endoscopy.Midazolam produced better amnesia for the procedure (P <0.0001) but diazepam and pethidine resulted in less retchingduring the procedure (P < 0.01) and less sedation after theprocedure, as judged by a simple performance test (P < 0.02)and patient recall of results (P < 0.02). ^*Department of Respiratory Medicine, East Birmingham HospitalBirmingham Department of Medicine, Section of Dermatology, University ofWales College of Medicine, Cardiff Department of Radiology, Royal Hallamshire Hospital Sheffield     

DELAYED EXCITATORY REACTION FOLLOWING INTERACTION OF COCAINE AND MONOAMINE OXIDASE INHIBITOR (PHENELZINE)

A case report is presented in which a patient receiving themonoamine oxidase inhibitor, phenelzine, developed a delayedexcitatory reaction following administration of topical cocainespray during anaesthesia for vocal cordsurgery. The pharmacologicalbasis of the drug interaction is discussed. ^*Department of Anaesthesia, St Bartholomew's Hospital, WestSmithfield, London EC1A 7BE. Shackleton Department of Anaesthetics, Southampton General Hospital,Tremona Road, Southampton S09 4XY. Harefield Hospital, Uxbridge, Middx UB9 6JH.     

THE AMNESIC EFFECT OF DIAZEPAM (VALIUM)

A double-blind trial of intravenous diazepam (0.24 mg/kg) versussaline was carried out on twelve young intelligent male volunteersto examine the amnesic effect of the drug. Complex psychologicaltesting extended over a 2-hour period. Dense anterograde amnesiawas found for approximately 10 minutes with a less severe impairmentof memory persisting at least half an hour after injection.It is considered that the memory difficulties were not due toserious reduction of level of consciousness but do focus onthe input or "consolidation" processes rather than on retrieval.Further studies are needed to define more clearly the natureof the deficit. ^*Whiteley Wood Clinic, Woofindin Road, Sheffield S10 3TL. Dept. of Anaesthetics, Royal Infirmary, Sheffield 6. Dept. of Psychology, University of Sheffield, Western Bank,Sheffield S10 2TN.     

EFFECTS OF ANAESTHETIC TECHNIQUE ON DEEP VEIN THROMBOSIS: A Comparison of Subarachnoid and General Anaesthesia

Forty patients with fractured neck of femur were allocated randomlyto undergo surgery under general anaesthesia (GA) or subarachnoidanaesthesia (SAB). After operation, the incidence of deep veinthrombosis (DVT), assessed by venography, was found to be 40%in the SAB group, which was significantly lower than the incidence(76.2%) in the GA group. These observations may account forthe previously reported effect of SAB, in comparison with GA,in reducing early postoperative mortality in this category ofpatient. ^*Nuffield Department of Anaesthetics, Radcliffe Infirmary,OxfordOX2 6HE. Department of Orthopaedic Surgery, Royal Liverpool Hospital,LiverpoolL7 8XP. University Department of Anaesthesia, Leicester Royal Infirmary,Leicester LEI 5WW.     

THE EFFECTS OF VARIATIONS IN END-EXPIRATORY INFLATION PRESSURE ON CARDIORESPIRATORY FUNCTION IN NORMO-, HYPO AND HYPERVOLAEMIC DOGS

The effects of altering end-expiratory inflation pressure werestudied in mechanically ventilated dogs in the normo-, hypo-and hypervolaemic state. The mean fall in cardiac output resultingfrom an increase in end-expiratory pressure was smaller in thehypervolaemic group than in the other two groups. A positiveend-expiratory pressure increased the mean deadspace/tidal volumeratio in all groups. A negative end-expiratory pressure increasedvenous admixture, particularly in the over-transfused animals,but the increase was not significant in the hypovolaemic group.A negative end-expiratory pressure did not affect deadspace/tidalvolume ratio. ^*Radcliffe Infirmary, Oxford Western Infirmary, Glasgow St George's Hospital, London Paddington Green Technical College, London     

THE USE OF DEHYDROBENZPERIDOL AND PHENOPERIDINE FOR REPEATED BURNS DRESSINGS: A Preliminary Communication

Neuroleptanalgesia has been used to permit dressing of severeburns on 76 occasions in 24 patients. Dehydrobenzperidol 10mg was given to all patients by intramuscular or intravenousinjection and was followed by phenoperidine given intravenouslyin an initial dose of 1 mg followed by incremental doses of0.5 to 1 mg. The procedure was successful in 70 instances andpartially successful in 6. Respiratory depression was the principalside effect but was easily managed in this series. This methodis considered to represent an advance over previous methodsof analgesia for burns dressings. ^*Present addresses:The London Hospital, London E.l. Present addresses:Harefield Hospital, Middlesex.     

COMPARISON OF FOUR LOCAL EXTRADURAL ANAESTHETIC SOLUTIONS FOR ELECTIVE CAESAREAN SECTION

We have examined a combination of two local anaesthetics tosee if the resultant solution is superior to the agents individually.This study shows that a mixture of bupivacaine and lignocaineprovided an excellent alternative to bupivacaine alone, andwas superior to 2% lignocaine with adrenaline for elective Caesareansection. By reducing the dose of bupivacaine used, the combinationmay reduce the risk of cardiotoxicity. An account of the preliminary results of this study was presentedat the autumn meeting of the Obstetric Anaesthetists Association,held at the University of Warwick in September 1989. ^*Present address: Charing Cross Hospital, London W6. Present address: Brompton Hospital, London SW3. ^¶Present address: Harefield Hospital, Middx. Present address: Hillington Hospital, Middx.     

A NEW TECHNIQUE FOR DOMICILIARY FLYING SQUAD ANAESTHESIA

A technique of domiciliary midwifery anaesthesia using Entonoxon a demand basis and minimal trichloroethylene is described.The method employs apparatus using the drawover principle, andalso includes facilities for neonatal resuscitation. ^*Liverpool Maternity Hospital, Liverpool 7. Department of Anaesthetics, Bristol University. Whiston Hospital, Prescot, Lanes.     

EFFECTS OF HIGHER OXIDES OF NITROGEN ON THE ANAESTHETIZED DOG

The physiological derangements during and following the administrationof higher oxides of nitrogen have been studied in dogs anaesthetizedwith pentobarbitone. The dogs were exposed to concentrationsof nitric oxide or nitrogen dioxide between 0.1 and 2.0 percent over periods between 5 and 136 minutes. Despite the inhalationof 98 per cent oxygen, death was always associated with a criticalreduction in arterial oxygen content. This was caused by oneor more of the following three factors: methaemoglobinaemia,low arterial Po₂, and acidaemia which caused a shift of theoxyhaemoglobin dissociation curve. The reduction of arterialPo₂ was caused by an outpouring of fluid into the alveoli. ^* In receipt of a Leverhulme Research Fellowship. In receipt of a grant from the Wellcome Foundation. Supported by U.S.P.H.S. Fellowship No. 1-F3-GM-31, 742-01,National Institute of General Medical Sciences. Seconded by the University of Washington, Seattle.     

EFFECT OF NALOXONE ON GASTRIC EMPTYING DURING LABOUR

The rate of gastric emptying was studied in 30 women duringlabour. All the women had received pethidine 100 mg i.m. foranalgesia and, subsequently, extradural analgesia had been establishedfor obstetric indications. The women were allocated randomlyto two groups: 15 received naloxone 1.2 mg i.v. and 15 weregiven saline 3 ml (placebo). All 30 patients were then givenparacetamol 1.5 g orally with water 100 ml. The amount of paracetamolabsorbed, and hence gastric emptying, was significantly greaterin the naloxone group in the first 30 min following the administrationof the paracetamol. ^*Present Addresses: Department of Anaesthesia, Southern GeneralHospital, 1345, Govan Road, Glasgow G51 4TF. Present addresses: Department of Anaesthesia, Ninewells Hospital,Dundee.     

EFFECTS OF SUBARACHNOID SPINAL NERVE BLOCK AND ARTERIAL PCO2 ON COLON BLOOD FLOW IN THE DOG

Changes in colon blood flow in greyhounds were measured in responseto acute changes in arterial PCO₂, before and after spinal nerveblock. Colon blood flow increased significantly after spinalnerve block, irrespective of PCO₂. The findings may be of clinicalimportance in man. ^*University Department of Anaesthesia, The General Hospital,Gwendolen Road, Leicester. Department of Surgery, Royal Infirmary, Glasgow. Victoria Infirmary, Glasgow.     

GENERAL ANAESTHESIA AND THE HYPEREOSINOPHILIC SYNDROME: SEVERE POSTOPERATIVE COMPLICATIONS IN TWO PATIENTS

Two patients with markedly increased eosinophil counts developedsevere postoperative complications after general anaesthesia.One patient suffered life-threatening Adult Respiratory DistressSyndrome (ARDS), while the other presented with a coagulopathyand less severe respiratory problems. The hypereosinophilicsyndrome is described and the possibility of a role of eosinophilsin the pathogenesis of tissue injury is discussed. These casessuggest that, in patients with marked eosinophilia requiringgeneral anaesthesia, perloperative steroid cover is advisable.This may reduce or prevent serious lung damage and other complications. ^*Present addresses: Department of Anaesthesia, The HammersmithHospital, DuCane Road, London W12 0HS. Department of Haematology, The Royal Free Hospital, Pond Street,London NW3 2QG.     

STIMULATION OF THE PERIPHERAL CHEMORECEPTORS WITH SODIUM BICARBONATE

The i.v. administration of sodium bicarbonate was found to causean increase in arterial pH, followed by an increase in Paco,-This caused a large increase in lung ventilation and in Pao,.Oxygen administration in human subjects, and anatomical denervationof the chemoreceptors in dogs, caused a substantial delay inthe ventilatory responses to sodium bicarbonate. It was concludedthat the i.v. administration of sodium bicarbonate providesa method of testing the presence of peripheral chemoreflexeswhich has the advantage of being independent of alveolar ventilation. ^*Present addresses: Institute of Bio-medical Electronics, Universityof Toronto, Toronto, Ontario, Canada. Department of Anaesthetics, Harefield Hospital, Harefield, Middlesex. Department of Anaesthetics, Burnley General Hospital, Lancashire.