The analgesic effect of lornoxicam when added to lidocaine for intravenous regional anaesthesia

Background. The aim of the study was to evaluate the effectof lornoxicam (L) on sensory and motor block onset time, tourniquetpain, and postoperative analgesia, when added to lidocaine inintravenous regional anaesthesia (IVRA). Methods. Forty-five patients undergoing hand surgery were randomlyand blindly divided into three groups as to receive either i.v.saline and IVRA with lidocaine 0.5% (Control group, n=15), i.v.saline and IVRA lidocaine 0.5% with lornoxicam (L-IVRA group,n=15), or intravenous lornoxicam and IVRA lidocaine 0.5% (L-IVgroup, n=15). Sensory and motor blocks onset time, and tourniquetpain was measured after tourniquet application at 5, 10, 20,and 30 min, and analgesic use were recorded during operation.After the tourniquet deflation, at 1, 30 min, and 2, 4 h, visualanalogue scales score, the time to first analgesic requirement,total analgesic consumption in first 24 h, and side effectswere noted. Results. Sensory and motor block onset times were shorter andthe recovery time prolonged in the Group L-IVRA compared withthe other group (P=0.001). A decreased tourniquet pain, a prolongedtime first analgesic requirement [229 (85) min vs 28 (20) and95 (24) min, P=0.0038) and less postoperative analgesic requirementsduring 24 h were found in Group L-IVRA compared with the othergroups (P<0.05). Conclusions. The addition of lornoxicam to lidocaine for intravenousregional anaesthesia shortens the onset of sensory and motorblock, decreases tourniquet pain and improves postoperativeanalgesia without causing any side effect.     

Spread of subarachnoid block, intraoperative local anaesthetic requirements and postoperative analgesic requirements in Caesarean section and total abdominal hysterectomy

Background. Pregnancy is associated with a higher spread ofsubarachnoid anaesthesia and increased pain threshold. The studywas designed to assess the spread of subarachnoid block andthe intra- and postoperative analgesic requirements in pregnantvs non-pregnant women. Methods. We assessed the level of subarachnoid anaesthesia after1.8 ml of hyperbaric lidocaine 5% and the postoperative analgesicrequirements in women undergoing Caesarean section and undergoingabdominal hysterectomy (30 each group). Intraoperatively epiduralropivacaine was given as required. All patients received 10ml of ropivacaine 0.2% epidurally 2, 10, and 24 h after operationand the VAS pain score was assessed. They also had access topatient controlled analgesia i.v. morphine. Results. Duration of surgery was 64 (13.7) vs 127 (33.8) min(P<0.0001) in the pregnant and non-pregnant groups. Ten minutesafter subarachnoid injection, sensory block was higher by threedermatomes in the pregnant group (P<0.0001). Time to firstropivacaine dose was 37 (19.7) vs 19 (12.2) min (P<0.001)and the ropivacaine normalized for the duration of anaesthesiawas 0.8 (0.6) vs 1.3 (0.5) mg^–1 (P=0.001) in the pregnantand non-pregnant groups, respectively. The time between thefirst and second ropivacaine dose was similar in the two groups(P=0.070). Fewer pregnant women (81 vs 100%) required ropivacaineintraoperatively (P=0.017). The VAS scores were similar butparturients consumed more i.v. morphine (33 (14) vs 24 (12)mg, P=0.016) during the first 24 h after operation. Conclusions. Pregnant patients exhibited a higher level of subarachnoidsensory block and required more i.v. morphine after operation.     

Differential effects of propofol, ketamine, and thiopental anaesthesia on the skeletal muscle microcirculation of normotensive and hypertensive rats in vivo

Background. This study utilized the dorsal microcirculatorychamber (DMC) model to determine differential effects of i.v.propofol, ketamine, and thiopental anaesthesia on the skeletalmuscle microcirculation (10–180 µm) of normotensive(Male Wistar Kyoto, WKY) and hypertensive (spontaneously hypertensiveHarlan, SHR) rats, importantly, comparing responses to a consciousbaseline. Methods. Three weeks following implantation of the DMC in WKY(n=8) and SHR (n=6) (130 g) 0.25 ml 100 g^–1 FITC–BSA(i.v.) was administered and the microcirculation viewed usingfluorescent in vivo microscopy for a 30 min baseline (t=0–30min). This was followed by either propofol, thiopental, ketamine,or saline (i.v. bolus induction over 5 min (t=30–35 min)),then maintenance step-up infusion for 60 min (t=45–105min), so that animals received all four agents 1 week apart(56 experiments). Results. Dilation of A3 arterioles (15–30 µm) andV3 venules (20–40 µm) with propofol was greaterin SHR (t=95 min, A3 36.7 (12)%, V3 15.5 (2.3)%) than WKY (t=95min, A3 19.4 (7.4)%, V3 8.0 (2.3)%) (P<0.05). Constrictionof A3 with ketamine was greater in SHR (t=95 min, A3 –29.1(6.4)%) than WKY (A3 –17.5 (8.8)%) (P<0.05). This wasaccompanied by hypotension with propofol in SHR (–32%decrease in systolic arterial pressure), but not WKY (–6%)and hypertension with ketamine in WKY (–15%) and SHR (–24%)(P<0.05). During thiopental anaesthesia there was dilationof A1 (80–180 µm), A3, and V3 in WKY (P<0.05).Conversely, in SHR dilation of venules (29.2 (8.7)%) was accompaniedby constriction of A1 and A3 (t=95 min, A1 –25.1 (5.9)%,A3 –45.2 (3.1)%) (P<0.05). Conclusion. Within the skeletal muscle microcirculation of hypertensiverats there is enhanced dilation with propofol and constrictionwith ketamine, associated with exaggerated changes in arterialpressure. Thus, dysfunctional control mechanisms at the levelof the microcirculation alter responses to anaesthesia duringhypertension.      

Comparison of ropivacaine 0.5% (in glucose 5%) with bupivacaine 0.5% (in glucose 8%) for spinal anaesthesia for elective surgery

Background. Hyperbaric solutions of ropivacaine have been usedsuccessfully to provide spinal anaesthesia. This study was designedto compare the clinical efficacy of hyperbaric ropivacaine withthat of the commercially available hyperbaric preparation ofbupivacaine. Methods. Forty ASA grade I–II patients undergoing lower-abdominal,perineal or lower-limb surgery under spinal anaesthesia wererecruited and randomized to receive ropivacaine 5 mg ml^–1(with glucose 50 mg ml^–1), 3 ml or bupivacaine 5 mg ml^–1(with glucose 80 mg ml^–1), 3 ml. The level and durationof sensory block, intensity and duration of motor block, andtime to mobilize and micturate were recorded. Patients wereinterviewed at 24 h and at 1 week to identify any residual problems. Results. All blocks were adequate for the proposed surgery,but there were significant differences between the two groupsin mean time to onset of sensory block at T10 (ropivacaine 5min; bupivacaine 2 min; P<0.005), median maximum extent (ropivacaineT7; bupivacaine T5; P<0.005) and mean duration of sensoryblock at T10 (ropivacaine 56.5 min; bupivacaine 118 min; P=0.001).Patients receiving ropivacaine mobilized sooner (ropivacainemean 253.5 min; bupivacaine 331 min; P=0.002) and passed urinesooner (ropivacaine mean 276 min; bupivacaine 340.5 min; P=0.01)than those receiving bupivacaine. More patients in the bupivacainegroup required treatment for hypotension (>30% decrease insystolic pressure; P=0.001). Conclusions. Ropivacaine 15 mg in glucose 50 mg ml^–1 providesreliable spinal anaesthesia of shorter duration and with lesshypotension than bupivacaine. The recovery profile for ropivacainemay be of interest given that more surgery is being performedin the day-case setting. Br J Anaesth 2003; 90: 304–8     

Sedation during spinal anaesthesia in infants

Background. Neuraxial anaesthesia in adults decreases the doseof i.v. or inhalational anaesthetic needed to reach a desiredlevel of sedation. Furthermore, spinal anaesthesia alone hasa sedative effect. The mechanism behind this phenomenon is presumedto be decreased afferent stimulation of the reticular activatingsystem after sympatholysis. We hypothesized that this mechanismis equally active in infants undergoing spinal anaesthesia. Methods. In total, 20 unpremedicated former preterm infantsunderwent surgery under spinal anaesthesia with hyperbaric bupivacaine0.5% 1 mg kg^–1 with epinephrine 10 µg kg^–1.No additional sedatives or anaesthetics were administered. Sedationwas evaluated using the bispectral index (BIS) score and the95% spectral edge frequency (SEF₉₅). Results. After spinal anaesthesia, mean (SD) BIS began to decreasesignificantly from baseline 97.0 (1.1) to 83.9 (14.4) after15 min (P=0.006). BIS decreased further, reaching the lowestvalues after 30 min [62.2 (14.0); P<0.00001]. Mean (SD) SEF₉₅declined from baseline 26.1 (1.8) Hz to 24.3 (3.1) after 5 min(P=0.02) and further to 9.9 (3.8) after 30 min (P<0.00001).Mean arterial pressure also decreased significantly from 66.5(4.7) mm Hg within 10 min to 56.1 (5.6) after spinal anaesthesia(P=0.0002), while heart rate remained stable. Conclusions. These results suggest that sedation after spinalanaesthesia in infants is at least as pronounced as in adults.The sedative effect of spinal anaesthesia should be kept inmind when additional sedatives are administered, especiallyin former preterm infants.     

Effect of intraoperative intravenous crystalloid infusion on postoperative nausea and vomiting after gynaecological laparoscopy: comparison of 30 and 10 ml kg(-1)

Background. I.V. fluid administration has been shown to reducepostoperative nausea and vomiting (PONV). The optimum dose isunknown. We tested the hypothesis that administration of i.v.crystalloid of 30 ml kg^–1 would reduce the incidence ofPONV compared with 10 ml kg^–1 of the same fluid. Methods. A total of 141 ASA I female patients undergoing electivegynaecological laparoscopy were randomized, in double-blindfashion, to receive either 10 ml kg^–1 (n=71; CSL-10 group)or 30 ml kg^–1 (n=70; CSL-30 group) of i.v. compound sodiumlactate (CSL). Results. In the first 48 h after anaesthesia, the incidenceof vomiting was lower in the CSL-30 group than in the CSL-10group (8.6% vs 25.7%, P=0.01). Anti-emetic use was less in theCSL-30 group at 0.5 h (2.9% vs 14.3%, P=0.04). The incidenceof severe nausea was significantly reduced in the treatmentgroup at awakening (2.9% vs 15.7%, P=0.02), 2 h (0.0% vs 8.6%,P=0.04) and cumulatively (5.7% vs 27.1%, P=0.001). The numbersneeded to treat to prevent vomiting, severe nausea and antiemeticuse in the first 48 h were 6, 5 and 6, respectively. Conclusion. I.V. administration of CSL 30 ml kg^–1 to healthywomen undergoing day-case gynaecological laparoscopy reducedthe incidence of vomiting, nausea and anti-emetic use when comparedwith CSL 10 ml kg^–1.     

Randomized controlled study of colloid preload before spinal anaesthesia for caesarean section

We randomized women having elective Caesarean section to receiveeither no preload (control group, n=33) or 4% gelatin solution(Gelofusine) 15 ml kg^–1 (colloid group, n=35)i.v. before spinal anaesthesia. Intravenous metaraminol wastitrated at 0.25–0.75 mg min^–1 to maintainsystolic arterial pressure (SAP) in the target range 90–100%of baseline after the spinal injection. The control group requiredmore vasopressor in the first 10 min [median 1.7 (range 0–2.9)mg vs 1.4 (0–2.8), P=0.02] at a greater maximum infusionrate [0.5 (0–0.75) vs 0.25 (0–0.5) mg min^–1,P=0.0005] and had a lower minimum SAP [90 (51–109) vs101 (75–127) mm Hg, P=0.006] than the colloid group. Nauseawas less frequent in the colloid group (6 vs 24%) but neonataloutcome was similar in the two groups. Colloid preload improvedhaemodynamic stability but did not affect neonatal outcome whenarterial pressure was maintained with an infusion of metaraminolduring spinal anaesthesia for Caesarean section. Br J Anaesth 2001; 87: 772–4     

Recovery of elderly patients from two or more hours of desflurane or sevoflurane anaesthesia

Background. The solubility of desflurane compared with sevofluranesuggests more rapid recovery from desflurane anaesthesia. Thiscould be important after prolonged anaesthesia and fast recoverymay be advantageous in the elderly where slow recovery of mentalfunction is a concern. We compared emergence from desfluranevs sevoflurane in elderly patients undergoing two or more hoursof anaesthesia. Methods. Fifty ASA physical status I, II, or III patients, 65yr of age or older, undergoing anaesthesia expected to lasttwo or more hours were randomly assigned to receive desflurane/nitrousoxide or sevoflurane/nitrous oxide anaesthesia. Patients weregiven 1–2 µg kg^–1 fentanyl i.v. and anaesthesiawas induced with propofol 1.5–2.5 mg kg^–1 i.v. andmaintained with either desflurane 2–6% or sevoflurane0.6–1.75% with nitrous oxide 65% in oxygen. Inspired anaestheticconcentrations were adjusted to obtain adequate surgical anaesthesiaand to maintain mean arterial pressure within 20% of baselinevalues. Early and intermediate recovery times were recorded.Digit-Symbol Substitution Test (DSST) scores and Visual AnalogScale (VAS) scores for pain and nausea were recorded beforepre-medication and every 15 min in the Post Anaesthesia CareUnit (PACU) until patients were discharged. Results. Early recovery times are given as median, quartiles.The times to extubation (5 (4–9); 9 (5–13) min),eye opening (5 (3–5); 11 (8–16) min), squeezingfingers on command (7 (4–9); 12 (8–17) min); andorientation (7 (5–9); 16 (10–21) min) were significantlyless (P<0.05) for desflurane than for sevoflurane. Intermediaterecovery, as measured by the DSST and time to ready for dischargefrom the PACU (56 (35–81); 71 (61–81) min) was similarin the two groups. Conclusions. Early but not intermediate recovery times of elderlypatients undergoing a wide range of surgical procedures requiringtwo or more hours of anaesthesia is significantly (P     

Parecoxib sodium has opioid-sparing effects in patients undergoing total knee arthroplasty under spinal anaesthesia

Background. This multicentre, double-blind, placebo-controlledstudy compared the opioid-sparing effectiveness and clinicalsafety of parecoxib sodium over 48 h, in 195 postoperativepatients after routine total knee replacement surgery. Methods. Elective total primary knee arthroplasty was performedunder spinal anaesthesia, with a single dose of spinal bupivacaine10–20 mg, and intraoperative sedation with midazolam0.5–1.0 mg i.v., or propofol <6 mg kg^–1h^–1. Patients were randomized to receive either parecoxibsodium 20 mg twice daily (bd) i.v. (n=65), parecoxib sodium40 mg bd i.v. (n=67), or placebo (n=63) at the completionof surgery, and after 12, 24, and 36 h. Morphine (1–2 mg)was taken by patient-controlled analgesia or by bolus dosesafter 30 min. Results. Patients receiving parecoxib sodium 20 mg bd and40 mg bd consumed 15.6% and 27.8% less morphine at 24 hthan patients taking placebo (both P<0.05). Both doses ofparecoxib sodium administered with morphine provided significantlygreater pain relief than morphine alone from 6 h (P<0.05).A global evaluation of study medication demonstrated a greaterlevel of satisfaction among patients taking parecoxib sodiumthan those taking placebo. Parecoxib sodium administered incombination with morphine was well tolerated. However, a reductionin opioid-type side-effects was not demonstrated in the parecoxibsodium groups. Conclusion. Parecoxib sodium provides opioid-sparing analgesiceffects in postoperative patients. Br J Anaesth 2003; 90: 166–72     

Propofol and halothane versus sevoflurane in paediatric day-case surgery: induction and recovery characteristics

Background. The aim of this study was to compare the inductionand recovery characteristics associated with propofol inductionand halothane maintenance with sevoflurane anaesthesia in paediatricday surgery. Methods. In total, 322 children were assigned randomly to i.v.propofol induction and halothane/nitrous oxide maintenance orsevoflurane/nitrous oxide alone. The patients’ age, sex,and type of surgery were recorded, as were the times requiredfor anaesthetic induction, maintenance, recovery and time todischarge home. Postoperative nausea and vomiting, and the incidenceof adverse events during induction and recovery were also noted. Results. No significant differences were detected in age, sex,type of surgery performed or intraoperative opioid administration.Excitatory movement was more common during induction with sevoflurane.The mean time required for induction with propofol was 3.1 mincompared with 5 min in the sevoflurane group (P<0.001). Therecovery time was shorter in the sevoflurane group comparedwith propofol/halothane (23.2 vs 26.4 min, P<0.002). Theincidence of delirium in recovery was greater in the sevofluranegroup (P<0.001). There was no difference between groups inthe time spent on the postoperative ward before discharge home.On the postoperative ward the incidence of both nausea and vomitingwas significantly higher in the sevoflurane group (P=0.034).Five children were admitted to hospital overnight, none foranaesthetic reasons. Conclusions. The increased incidence of adverse events duringinduction, postoperative nausea and vomiting and postoperativedelirium in the sevoflurane group suggests that sevofluraneis not ideal as a sole agent for paediatric day case anaesthesia. Br J Anaesth 2003; 90: 461–6     

BIS guided sedation with propofol during spinal anaesthesia: influence of anaesthetic level on sedation requirement

Background. In this prospective, clinical study we tested thehypothesis whether two different doses of spinal administeredbupivacaine and accordingly, two different levels of spinalanaesthesia can affect the dose requirement of propofol duringBIS guided sedation. Methods. Fifty women undergoing vaginal hysterectomy (high spinalgroup, HS) or transvaginal tape (TVT) procedure for urinaryincontinence (low spinal group, LS) under spinal anaesthesiawere enrolled to the study. In group HS, 17.5 mg and in groupLS, 7.5 mg of hyperbaric bupivacaine were given intrathecally.After 15 min to obtain the appropriate level of spinal anaesthesia,propofol infusion was started at a rate of 100 µg kg^–1min^–1 to reach a BIS level of less than 75 (onset time),and titrated to maintain the BIS value between 65 and 75. Propofolinfusion was stopped 45 min after placing the spinal to measurethe time to reach a BIS level of 90 (recovery time). Results. Median anaesthetic level was T3 (T1–4) in theHS group and T10 (T9-11) in the LS group. In both the HS andthe LS groups, onset time was 226 (47) vs 273 (48) s (P=0.001),recovery time was 234 (47) vs 202 (56) s (P=0.03), total doseof propofol was 2.17 (0.43) vs 3.14 (0.56) mg kg^–1 (P<0.001),respectively. Conclusion. A high spinal block obtained with hyperbaric bupivacaine17.5 mg was associated with a faster onset, delayed recoveryand lower doses of propofol sedation compared with a low spinalblock with 7.5 mg of the same drug.     

Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery

Background. Previously, plain ropivacaine 15 mg given intrathecallyhas been shown to be feasible for ambulatory surgery of lower-extremities.Hypothetically, hyperbaric solution could improve and shortenthe block. Methods. This prospective, randomized, double-blind study included56 patients undergoing surgery of lower extremities. They receivedintrathecally either 1.5 ml of ropivacaine 10 mg ml^–1and 0.5 ml of glucose 300 mg ml^–1 (HYP) or 2 ml of ropivacaine7.5 mg ml^–1 (PL). Results. All patients in Group HYP achieved T₁₀ dermatome analgesiabut only 64% (18/28) of Group PL. T₁₀ analgesia was reachedin 5 min (median, range 5–20 min) in the HYP group vs10 min (5–45 min) in the PL group (P=0.022), and fullmotor block in 10 min (5–45 min) vs 20 min (5–60min) (P=0.003), respectively. Group HYP had a longer durationof analgesia at T₁₀; 83 min (5–145 min) vs 33 min (0–140min) (P=0.004). Duration of sensory block from injection ofthe anesthetic to complete recovery was shorter in Group HYPthan in Group PL, 210 min (120–270 min) vs 270 min (210–360min) (P<0.001), as was duration of motor block, 120 min (5–150min) vs 210 min (120–330 min) (P<0.001). Patients ofGroup HYP attained discharge criteria earlier than those ofGroup PL (P=0.009). Conclusion. In comparison with the plain solution, 15 mg ofintrathecal hyperbaric ropivacaine produced a faster onset,greater success rate of analgesia at the level of T₁₀ dermatome,and faster recovery of the block.     

Articaine versus lidocaine plus bupivacaine for peribulbar anaesthesia in cataract surgery

Background. We compared the efficacy and safety of articaine2% with a mixture of lidocaine 2% and bupivacaine 0.5% withouthyaluronidase for peribulbar anaesthesia in cataract surgery. Method. In this double-blind randomized clinical study, 58 cataractpatients were allocated to receive either articaine 2% withepinephrine 1:200 000 or a mixture of equal parts of lidocaine2% with epinephrine 1.25:100 000 and bupivacaine 0.5%. Ocularand eyelid movement scores, the number of supplementary injections,total volume of solution used and pain and complications duringinjection and surgery were used as clinical end-points. Results. Articaine produced greater akinesia after 5 min (P=0.03).Eighteen patients (60%) in the articaine group and 26 (93%)in the lidocaine/bupivacaine group required a second injection(P=0.003). A third injection was needed by two patients (7%)in the articaine group and 12 (43%) in the lidocaine/bupivacainegroup (P=0.001). The total mean volume of local anaestheticrequired to achieve akinesia was mean 9.4 (SD 1.7) ml in thearticaine group and 11.28 (1.86) ml in the lidocaine/bupivacainegroup (P<0.001). Median pain score was lower in the articainegroup than in lidocaine/bupivacaine group during injection (P=0.004)and surgery (P=0.014). There was no difference between the groupsfor the incidence of complications. Conclusion. Articaine 2% without hyaluronidase is more advantageousthan a mixture of lidocaine 2% and bupivacaine 0.5% withouthyaluronidase for peribulbar anaesthesia in cataract surgery. Br J Anaesth 2004; 92: 231–4     

Inspired oxygen fraction of 0.8 compared with 0.4 does not further reduce postoperative nausea and vomiting in dolasetron-treated patients undergoing laparoscopic cholecystectomy

Background. Postoperative nausea and vomiting (PONV) is oneof the most frequent complications after general anaesthesia.Single-dose antiemetic prophylaxis has limited efficacy in high-riskpatients. Adding a simple potential antiemetic approach, suchas increasing the inspired oxygen fraction, to the antiemeticportfolio would preserve pharmacological interventions for treatmentof symptoms in the postoperative period. However, the antiemeticeffect of a high inspired oxygen fraction is still discussedcontroversially. The aim of the study was to evaluate whetheran inspired oxygen fraction of 0.8 decreases PONV in patientsreceiving the 5-HT₃-antagonist dolasetron. Methods. In a randomized, placebo-controlled, double-blindedtrial we studied 377 patients (ASA I–III) undergoing electivelaparoscopic cholecystectomy. Induction of anaesthesia was standardized,including thiopental fentanyl and cis-atracurium. For all patientsthe individual risk for PONV was calculated using the Koivurantascore and all patients received 12.5 mg dolasetron i.v. beforesurgery. Patients were allocated randomly to one of three groups:Group A (n=125) received 80% oxygen in air, Group B (n=125)40% oxygen in air and Group C (n=127) 40% oxygen in nitrousoxide. Postoperative nausea, postoperative vomiting (PV), ornausea, vomiting, or both (PONV) was assessed in the early (0–4h) and overall postoperative period (0–24 h) by an anaesthesiologistunaware of patient allocation. Results. There was a significantly lower incidence of PONV andPV in Groups A (PONV: 11.2%; PV: 3.2%) and B (PONV: 10.4%; PV:3.2%) compared with Group C (PONV: 26.7%; PV: 13.3%), but therewere no significant differences between Groups A and B. Conclusions. An inspired oxygen fraction of 0.8 does not furtherdecrease PONV or vomiting in dolasetron-treated patients undergoinglaparoscopic cholecystectomy. The lower incidence of PONV inGroups A and B compared with Group C is most likely caused bythe omission of nitrous oxide.      

Comparison of propofol/remifentanil and sevoflurane/remifentanil for maintenance of anaesthesia for elective intracranial surgery

Background. Propofol and sevoflurane are suitable agents formaintenance of anaesthesia during neurosurgical procedures.We have prospectively compared these agents in combination withthe short-acting opioid, remifentanil. Methods. Fifty unpremedicated patients undergoing elective craniotomyreceived remifentanil 1 µg kg^–1 followed by an infusioncommencing at 0.5 µg kg^–1 min^–1 reducing to0.25 µg kg^–1 min^–1 after craniotomy. Anaesthesiawas induced with propofol, and maintained with either a target-controlledinfusion of propofol, minimum target 2 µg ml^–1 orsevoflurane, initial concentration 2%_ET. Episodes of mean arterialpressure (MAP) more than 100 mm Hg or less than 60 mm Hg formore than 1 min were defined as hypertensive or hypotensiveevents, respectively. A surgical assessment of operating conditionsand times to spontaneous respiration, extubation, obey commandsand eye opening were recorded. Drug acquisition costs were calculated. Results. Twenty-four and twenty-six patients were assigned topropofol (Group P) and sevoflurane anaesthesia (Group S), respectively.The number of hypertensive events was comparable, whilst morehypotensive events were observed in Group S than in Group P(P=0.053, chi-squared test). As rescue therapy, more labetolol[45 (33) vs 76 (58) mg, P=0.073] and ephedrine [4.80 (2.21)vs 9.78 (5.59) mg, P=0.020] were used in Group S. Between groupdifferences in recovery times were small and clinically unimportant.The combined hourly acquisition costs of hypnotic, analgesic,and vasoactive drugs appeared to be lower in patients maintainedwith sevoflurane than with propofol. Conclusion. Propofol/remifentanil and sevoflurane/remifentanilboth provided satisfactory anaesthesia for intracranial surgery.     

Nausea and vomiting after fast-track cardiac anaesthesia

Background. The aim of this study was to determine the prevalenceof postoperative nausea and vomiting (PONV) after fast-trackcardiac anaesthesia, risk factors for PONV and its influenceon the length of stay in the intensive care unit (ICU). Methods. A prospective study was performed in the cardiothoracicICU (CTICU) of a university hospital; 1221 consecutive patientsundergoing fast-track anaesthesia (FTCA) in cardiac surgerywere enrolled in the study. Severity of PONV was assessed immediatelyafter extubation and then every hour until discharge from theCTICU. Metoclopramide 10 mg i.v. was used as a first-line rescuemedication and ondansetron 4 mg i.v. as second-line rescue medicationfor PONV. Results. Nausea was reported in 240 (19.7%) patients, and vomitingin 53 (4.3%). A total of 269 (22%) patients were treated withmetoclopramide and 38 (3.1%) with metoclopramide and ondansetron.The latter was effective in all cases. Risk factors for PONVwere age less than 60 yr, female gender and previous historyof PONV. Discharge from the CTICU was delayed for a few hoursbecause of PONV in eight patients, all of whom were dischargedthe same day. Conclusions. The incidence of PONV is relatively low after FTCAand does not prolong ICU stay. Prophylactic administration ofanti-emetic drugs before FTCA is not necessary. Br J Anaesth 2003; 91: 214–17     

Effect of peri- and postoperative epidural anaesthesia on pain and gastrointestinal function after abdominal hysterectomy

In a double blind study we have investigated the effects ofepidural local anaesthesia (LA), when added to general anaesthesia(GA) and postoperative paracetamol and NSAID, on postoperativepain and gastrointestinal function in patients undergoing openhysterectomy. Sixty patients were randomized into three studygroups: GA, and postoperative paracetamol and NSAID (GA, n=20);GA, paracetamol, NSAID, intraoperative epidural lidocaine and24-h postoperative epidural saline (Saline, n=20); or GA, paracetamol,NSAID, intraoperative epidural lidocaine and 24-h postoperativeepidural bupivacaine (Bupi, n=20). Patients were observed for72 h postoperatively. Pain at rest, during cough, and mobilization,request for supplementary morphine, and time to first postoperativeflatus, was reduced in patients receiving 24-h postoperativeepidural anaesthesia, compared with the two other groups. However,these effects of epidural LA, were not sustained beyond theperiod of infusion, and no differences in PONV, time to firstpostoperative defecation, mobilization or time to dischargefrom hospital were observed between groups. A 24 h postoperativeepidural infusion with bupivacaine, when added to postoperativeparacetamol and NSAID, reduces pain and opioid requirements,but has only limited effects on gastrointestinal function andpatient recovery. Br J Anaesth 2001; 87: 577–83     

Magnesium sulphate as a technique of hypotensive anaesthesia

Background. This randomized, double-blind, placebo-controlledstudy was designed to assess the effect of perioperatively administeredi.v. magnesium sulphate as a technique of hypotensive anaesthesia. Methods. Sixty patients (25 female) undergoing functional endoscopicsinus surgery were included in two parallel groups. The magnesiumgroup received magnesium sulphate 40 mg kg^–1 i.v. as abolus before induction of anaesthesia and 15 mg kg^–1 h^–1by continuous i.v. infusion during the operation. The same volumeof isotonic solution was administered to the control group.Intraoperative bleeding was evaluated using a quality scale. Results. In the magnesium group, there was a reduction in surgicaltime [68.1 (15.6) min vs 88.1 (10.7) min], although the anaesthetictime was 10 min longer and thus presuming a prolongation inanaesthetic emergence. There was a significant reduction ofblood loss [165 (19) ml vs 257 (21) ml]. The anaesthetic requirements(fentanyl, vercuronium and sevoflurane), mean arterial bloodpressure (P<0.005) and heart rate (P<0.005) were alsosignificantly reduced. Conclusion. Magnesium sulphate led to a reduction in arterialpressure, heart rate, blood loss and duration of surgery. Furthermore,magnesium infusion alters anaesthetic dose requirements andemergence time.     

Fluoride excretion in children after sevoflurane anaesthesia

Background. Defluorination of sevoflurane is catalysed by thehepatic enzyme cytochrome P450 2E1 (CYP2E1). Data about theontogenesis (developmental variations in activity) of this enzymesuggest a low metabolism of sevoflurane during the first monthsof life. Methods. To test this hypothesis, 45 children less than 48 monthsof age undergoing sevoflurane anaesthesia were enrolled in aprospective open clinical trial. The 24 h urine fluoride excretionwas measured in five groups of children (A, <4 months; B,4 to <8 months; C, 8–12 months; D, >12–24months; and E, >24–48 months old). An index of sevofluranemetabolism (ISM) was calculated as the ratio of fluoride excretion,cumulative expiratory sevoflurane concentrations measured everyminute during anaesthesia, and body surface area. ISM valueswere median (IQ 25–75%). Results. ISM was lower in group A (n=9, 18.9 (11.2–29.5)than group C (n=11, 44.2 (37.5–53.5), P<0.05), groupD (n=7, 52.6 (45.8–68.4), P<0.01) and group E (n=9,53.6 (50.7–85), P<0.001). Median ISM expressed as afunction of median age, exponentially increased with a rapidincrease during the first months of life, followed by a slowerincrease after 10 months of age. Conclusion. These results suggest that, in children less than48 months, sevoflurane metabolism parallels postnatal developmentof CYP2E1. Br J Anaesth 2002; 89: 693–6     

Cerebral haemodynamic changes during propofol-remifentanil or sevoflurane anaesthesia: transcranial Doppler study under bispectral index monitoring

Background. Sevoflurane or propofol–remifentanil-basedanaesthetic regimens represent modern techniques for neurosurgicalanaesthesia. Nevertheless, there are potential differences relatedto their activity on the cerebrovascular system. The magnitudeof such difference is not completely known. Methods. In total 40 patients, treated for spinal or maxillo-facialdisorders, were randomly allocated to either i.v. propofol–remifentanilor inhalational sevoflurane anaesthesia. Transcranial Dopplerwas used to assess changes in cerebral blood flow velocity,carbon dioxide reactivity, cerebral autoregulation and the bispectralindex to assess the depth of anaesthesia. Results. Time-averaged mean flow velocity (MFV) was significantlyreduced after induction of anaesthesia in both sevoflurane andpropofol–remifentanil groups (P<0.001). At deeper levelsof anaesthesia, MFV increased in the sevoflurane group, suggestingan uncoupling flow/metabolism, whereas it was further reducedin the propofol–remifentanil group (P<0.001). Indicesof cerebral autoregulation were reduced in patients with high-dosesevoflurane whereas autoregulation was preserved in patientsanaesthetized with propofol–remifentanil (P<0.001).Higher CO₂ concentrations impaired cerebral autoregulation inthe sevoflurane group but not in patients anaesthetized withpropofol–remifentanil. Conclusions. Propofol–remifentanil anaesthesia induceda dose-dependent low-flow state with preserved cerebral autoregulation,whereas sevoflurane at high doses provided a certain degreeof luxury perfusion.