Comparison of the effects of thoracic epidural analgesia and i.v. infusion with lidocaine on cytokine response, postoperative pain and bowel function in patients undergoing colonic surgery

Background. Both thoracic epidural analgesia (TEA) and i.v.lidocaine were able to decrease postoperative pain and durationof ileus. We compared TEA and i.v. lidocaine (IV) regardingtheir effects on cytokines, pain and bowel function after colonicsurgery. Methods. Sixty patients were randomly allocated to one of thethree groups. TEA group had lidocaine 2 mg kg^–1 followedby 3 mg kg^–1 h^–1 epidurally and an equal volumeof i.v. normal saline. The IV group received the same amountof lidocaine i.v. and normal saline epidurally. The controlgroup received normal saline via both routes. These regimenswere started 30 min before surgery and were continued throughout.Blood cytokines were measured at scheduled times within 72 h. Results. Both TEA and IV groups had better pain relief. Thetotal consumptions using patient-controlled epidural analgesiawere 81.6 (6.5), 55.0 (5.3) and 45.6 (3.9) ml (P<0.01) andthe times of flatus passage were 50.2 (4.9), 60.2 (5.8) and71.7 (4.7) h (P<0.01) in the TEA, IV and control groups,respectively. The TEA group exhibited the best postoperativepain relief and the least cytokine surge. The IV group experiencedbetter pain relief and less cytokine release than the controlgroup. Conclusions. The TEA lidocaine had better pain relief, loweropioid consumption, earlier return of bowel function and lesserproduction of cytokines than IV lidocaine during 72 h aftercolonic surgery; IV group was better than the control group.     

Is morphine-induced sedation synonymous with analgesia during intravenous morphine titration?

Background. Postoperative morphine titration frequently inducessedation. The assumption is made that patients sleep when theirpain is relieved. Some patients complain of persistent painwhen they awake. We studied the time-course of sedation andanalgesia to understand the determinants of patients’sleep during morphine titration. Methods. Seventy-three patients requiring morphine titrationin a post-anaesthetic care unit after major surgery, were studied.Fifty-two patients slept (Sleep group) and 21 did not (Awakegroup). When a patient slept during titration, morphine wasdiscontinued. Visual analogue pain scale (VAS), Ramsay score(RS), and the bispectral index (BIS) were recorded at the beginningof titration (STonset), at sleep onset (STsleep), then 5, 10,20, and 30 min afterwards (ST4). Results. In the Sleep group, mean (SD) RS increased from 1.7(0.4) to 2.4 (0.6) (P<0.05 vs STonset) and BIS decreasedfrom 95 (5.0) to 89.8 (10.2) between STonset and STsleep (P<0.05),RS remained stable thereafter. Conversely, RS and BIS remainedunaltered in the Awake group. The reduction in VAS was comparablebetween groups (from 78 (17) to 39 (21), and from 64 (16) to30.4 (11), respectively). Even though mean (SD) VAS was 39 (21)at ST4 in the Sleep group, 13 patients (25%) maintained a VASabove 50 mm. Conclusion. We observed dissociated effects of morphine on thetime-course of sedation and analgesia with sedation occurringfirst, followed by analgesia. Therefore, morphine-induced sedationshould not be considered as an indicator of an appropriate correctlevel of analgesia during i.v. morphine titration. Br J Anaesth 2002; 89: 697–701     

Cardiovascular changes with the laryngeal mask airway in cardiac anaesthesia

Background. The laryngeal mask airway (LMA) causes fewer haemodynamicchanges, particularly in mean arterial pressure (MAP) and heartrate (HR), than tracheal intubation using either laryngoscopyor the intubating LMA. There are no data for patients with coronaryartery disease. Method. We studied 27 patients having coronary artery bypassgrafting, prospectively randomized to be managed with eitherthe LMA or tracheal intubation using either laryngoscopy orthe ILMA. We used invasive monitoring to compare the haemodynamiceffects in each group during induction and emergence from anaesthesia. Results. Both methods of intubation caused an increase in MAPcompared with the LMA (P<0.05). Mixed venous oxygen saturationincreased in the intubated patients but not with the LMA (P<0.05).HR did not change at induction in the LMA group. Changes atextubation were similar in all groups but cardiac index waslower in the LMA group (P<0.05). Conclusion. The LMA allows airway management without hypertensionand tachycardia and should be considered when anaesthetizingpatients with coronary disease. Br J Anaesth 2004; 92: 885–7     

Auditory evoked response during propofol anaesthesia after pre-induction with midazolam

Background. In clinical use, midazolam reduces the dose requirementfor propofol. We studied the effect of midazolam given beforeanaesthesia on the amount of propofol needed and the time taken,to achieve loss of consciousness (LOC) in 20 patients. Methods. We compared the auditory evoked responses (AER) inthese patients with those in a group of 20 patients who werenot given midazolam. Results. LOC, as defined by a loss of response to verbal commandand eyelash reflex, occurred after 113 (95% CI, 99–131)s in the control group and 75 (56–101) s in the midazolamgroup (P<0.05). In the control group 2.3 (2.0–2.6)mg kg^–1 propofol caused LOC compared with 1.3 (1.1–1.5)mg kg^–1 in the group pretreated with midazolam (P<0.001).Pa amplitude decreased by 60% in the control group and by 54%in the midazolam group while Nb latency increased by 24% inthe control group and by 32% in the midazolam group followingLOC. These differences were not significant. Conclusions. We confirmed that coinduction of anaesthesia withmidazolam and propofol reduces the requirement of propofol.We also demonstrated that the AER reflects anaesthetic depthrather than plasma concentrations of anaesthetic drugs. Br J Anaesth 2002; 89: 325–7     

Monitoring of neuromuscular block after administration of vecuronium in patients with diabetes mellitus

Background. We studied the supramaximal current for ulnar nervestimulation during electromyographic monitoring of onset andrecovery of neuromuscular block using a neuromuscular transmissionmodule (M-NMT Module, Datex-Ohmeda) in patients with Type 2diabetes undergoing anaesthesia with nitrous oxide, oxygen,isoflurane and fentanyl. Methods. Thirty-six diabetic patients were randomly assignedto a post-tetanic count (PTC) group (n=17) or train-of-four(TOF) group (n=19). In addition, 30 non-diabetic patients weredivided into control PTC (n=15) and TOF groups (n=15). Results. In the diabetic patients (diabetes PTC and diabetesTOF groups), the mean supramaximal stimulating current was significantlyhigher than in the non-diabetic patients (control PTC and TOFgroups) (50.5 (SD 14.1) vs 33.4 (6.1) mA, P<0.01). Onsetof neuromuscular block (time to disappearance of T1) after vecuronium0.1 mg kg^–1 in the diabetic patients did not differ significantlyfrom that in the non-diabetic patients (276 (77) vs 244 (44)s, P=0.055). Time to return of PTC1 did not differ significantlybetween the diabetes and control PTC groups (21.0 (12.1) vs15.7 (5.0) min, P=0.126). Times to return of T1 and T4 in thediabetes TOF group were significantly longer than in the controlTOF group (T1: 37.5 (15.2) vs 25.7 (7.6) min, P=0.01; T4: 61.4(23.7) vs 43.5 (11.4) min, P=0.01). During recovery, PTC andT4/T1 in the diabetes PTC and TOF groups were similar to thosein the control PTC and TOF groups, respectively. T1/T0 in thediabetes TOF group was significantly less than in the controlTOF group, 80–120 min after vecuronium (P<0.05). Conclusions. In diabetic patients, supramaximal current is higherthan in non-diabetic patients. After vecuronium, onset of neuromuscularblock and recovery of PTC or T4/T1 are not altered, but timeto return of T1 or T4, and recovery of T1/T0 are delayed indiabetic patients. Br J Anaesth 2003; 90: 480–6     

In-vivo induction of monocyte chemotactic and activating factor in patients with chronic renal failure

BACKGROUND: Monocyte chemotactic and activating factor (MCAF) is a novelinflammatory cytokine belonging to the chemokine superfamilyand stimulates chemotaxis and activation of monocytes. Increasedproduction of inflammatory cytokines has been shown in patientswith end-stage renal disease (ESRD). This study was thus conductedto determine plasma MCAF in patients with ESRD. METHODS: Plasma levels of MCAF were determined by ELISA. Gene expressionof MCAF in PBMC was assessed by RT-PCR followed by southernblot hybridization. RESULTS: Plasma MCAF in 72 patients with long-term haemodialysis (HD)(162.4 ± 58.2 pg/ml) and eight uraemic patients not yetdialysed (167.6 ± 57.7 pg/ml) was found to exceed significantlythe level in 24 normal subjects (86.0±19.4 pg/ml). MCAFbefore HD session in long-term HD patients was the same whetherHD was carried out with either cellulosic (CUP) or synthetic(PMMA) membrane dialysers. Intradialytic increase in plasmaMCAF during a single HD session was observed in both patientgroups dialysed with CUP or PMMA membranes. The results of RT-PCRanalysis indicated that haemodialysis stimulates the gene expressionof MCAF in PBMC in vivo. CONCLUSIONS: The present results indicate that increased levels of plasmaMCAF may promote the activation of monocytes in patients withESRD.     

The open lung concept: effects on right ventricular afterload after cardiac surgery

Background. The open lung concept (OLC) is a method of ventilationintended to maintain end-expiratory lung volume by increasedairway pressure. Since this could increase right ventricularafterload, we studied the effect of this method on right ventricularafterload in patients after cardiac surgery. Methods. We studied 24 stable patients after coronary arterysurgery and/or valve surgery with cardiopulmonary bypass. Patientswere randomly assigned to OLC or conventional mechanical ventilation(CMV). In the OLC group, recruitment manoeuvres were applieduntil was greater than 50 kPa (reflecting an open lung). This value was maintained by sufficient positiveairway pressure. In the CMV group, volume-controlled ventilationwas used with a PEEP of 5 cm H₂O. Cardiac index, right ventricularpreload, contractility and afterload were measured with a pulmonaryartery thermodilution catheter during the 3-h observation period.Blood gases were monitored continuously. Results. To achieve > 50 kPa, 5.3 (3) (mean, SD) recruitment attempts were performed with a peak pressureof 45.5 (2) cm H₂O. To keep the lung open, PEEP of 17.0 (3)cm H₂O was required. Compared with baseline, pulmonary vascularresistance and right ventricular ejection fraction did not changesignificantly during the observation period in either group. Conclusion. No evidence was found that ventilation accordingto the OLC affects right ventricular afterload.     

Intra-articular injection of warmed lidocaine improves intraoperative anaesthetic and postoperative analgesic conditions

Background. Although local anaesthesia for knee arthroscopyis a well-documented procedure, arthroscopy under local anaesthesiais often interrupted because of intolerable discomfort and pain.Warming local anaesthetic solutions may increase its anaestheticeffect. We tested whether intra-articular injection of warmedlidocaine solution could improve intraoperative anaestheticand postoperative analgesic conditions. Methods. Patients in the warmed group received 20 ml warmed(40°C) lidocaine 1% intra-articularly 20 min before surgery.The patients in the control group received 20 ml room-temperature(25°C) lidocaine 1% intra-articularly 20 min before surgery.During surgery, the patients reported pain on a visual analoguescale (VAS). Results. The median VAS pain score was 1.5 (range, 0.0–3.0)in the warmed lidocaine group and 5.0 (4.0–8.0) in thecontrol group (P<0.001). The median intra- and postoperativeanalgesic requirements in the control group were significantlygreater than that in the warmed group. Conclusion. Warmed lidocaine injected intra-articularly providesimproved intraoperative anaesthetic and postoperative analgesicconditions for patients undergoing knee arthroscopy.     

Pharmacokinetics and haemodynamics of ketamine in intensive care patients with brain or spinal cord injury

Background. Ketamine is used as an anaesthetic agent for shortsurgical procedures, and as a sedative and analgesic in intensivecare patients. Intensive care patients with brain or spinalcord injury may have physiological changes that could alterthe pharmacokinetics of ketamine. The pharmacokinetics of ketaminehave been studied in healthy volunteers and in patients undergoingdifferent types of surgery, but no data are available in intensivecare patients. Methods. We determined the pharmacokinetics of ketamine andits active metabolites, norketamine and dehydronorketamine,in 12 intensive care patients with brain or spinal cord injury.The effect of ketamine on haemodynamic variables was also investigated. Results. The total clearance of ketamine, mean (SD), was 36.0(13.3) ml min^–1 kg^–1, the volume of distribution(Vß) was 16.0 (8.6) litre kg^–1, and the eliminationhalf-life was 4.9 (1.6) h. Ketamine did not alter any haemodynamicvariables in the patients studied. Conclusions. Pharmacokinetic variables of ketamine in intensivecare patients are greater than in healthy volunteers and insurgical patients. The increase in the volume of distributionis greater than the increase in clearance, resulting in a longerestimated half-life of ketamine in this patient group. Br J Anaesth 2003; 90: 155–60     

Propofol attenuates myocardial lipid peroxidation during coronary artery bypass grafting surgery

Background. Propofol can scavenge free radicals because it hasa chemical structure similar to antioxidants. Methods. We examined if free radical scavenging occurs withpropofol during CABG operations. We studied 24 patients undergoingCABG surgery for triple vessel disease, randomized into twogroups. After induction of anaesthesia with fentanyl 10 µgkg^–1 and midazolam 0.1 mg kg^–1, patients in thefentanyl group (n=14) received fentanyl infusion 10–30µg kg^–1 h^–1 and patients in the propofol group(n=10) received propofol infusion 3–6 mg kg^–1 h^–1for maintenance of anaesthesia. Atrial tissue biopsies weretaken during cannulation for bypass, 45 min after cross-clampinsertion, 5 min after unclamping, and in the decannulationperiod. Lipid peroxidation was assessed by measurement of thiobarbituricacid reactive substances (TBARS) in the atrial tissue samples. Results. Lipid peroxidation in the propofol group was less thanin the fentanyl group (P<0.05) in all sampling periods. Lipidperoxidation in the fentanyl group increased significantly duringcardiopulmonary bypass (CPB) (P<0.05), but no increase wasfound in the propofol group (P>0.05). Conclusion. In clinical doses, propofol strongly attenuateslipid peroxidation during CABG surgery. Br J Anaesth 2002; 89: 242–6     

Xenon has no effect on cytokine balance and adhesion molecule expression within an isolated cardiopulmonary bypass system

Background. Although almost inert chemically, xenon is not unreactivebiologically. It interacts with receptors involved in the expressionof cytokines and adhesion molecules. The effect of xenon onthe immune function in whole blood has not been studied. Methods. We examined the effects of 70% xenon in oxygen on cytokinebalance and expression of adhesion molecules in an isolatedcardiopulmonary bypass (CPB) system, which simulates an evolvinginflammatory response. Whole blood from 10 healthy male volunteerswas circulated in a CBP system supplied with either 70% xenonin oxygen, or oxygen-enriched air – FO₂=0.3 (control).We took samples of blood after 30, 60 and 90 min of simulatedCBP. We measured interleukin (IL)-1ß, tumour necrosisfactor (TNF)     

Cerebrospinal fluid and blood propofol concentration during total intravenous anaesthesia for neurosurgery

Background. The aim of this paper is to compare the propofolconcentration in blood and cerebrospinal fluid (CSF) in patientsscheduled for different neurosurgical procedures and anaesthetizedusing propofol as part of a total intravenous anaesthesia technique. Methods. Thirty-nine patients (ASA I–III) scheduled forelective intracranial procedures, were studied. Propofol wasinfused initially at 12 mg kg^–1 h^–1 and thenreduced in steps to 9 and 6 mg kg^–1 h^–1. Duringanaesthesia, bolus doses of fentanyl and cis-atracurium wereadministered as necessary. After tracheal intubation the lungswere ventilated to achieve normocapnia with an oxygen-air mixture(FI_O2=0.33). Arterial blood and CSF samples for propofol examinationwere obtained simultaneously directly after intracranial drainageinsertion and measured using high-performance liquid chromatography.The patients were divided into two groups depending on the typeof neurosurgery. The Aneurysm group consisted of 13 patientswho were surgically treated for ruptured intracranial aneurysm.The Tumour group was composed of 26 patients who were undergoingelective posterior fossa extra-axial tumour removal. Results. Blood propofol concentrations in both groups did notdiffer significantly (P>0.05). The propofol concentrationin CSF was 86.62 (SD 37.99) ng ml^–1 in the Aneurysm groupand 50.81 (26.10) ng ml^–1 in the Tumour group (P<0.005). Conclusions. Intracranial pathology may influence CSF propofolconcentration. However, the observed discrepancies may alsoresult from quantitative differences in CSF composition andfrom restricted diffusion of the drug in the CSF. Br J Anaesth 2003; 90: 84–6     

Genotype and interleukin-10 responses after cardiopulmonary bypass

Background. The pro- and anti-inflammatory cytokine balancehas been implicated in outcome from inflammatory conditions,and cardiopulmonary bypass is associated with a marked inflammatoryresponse. Interleukin-10 (IL-10) is an anti-inflammatory cytokineand levels have been shown to be highest in those patients whodevelop sepsis after trauma or surgery. IL-10 levels vary betweenindividuals and genotype may dictate the IL-10 response. Wetherefore investigated IL-10 genotype, circulating IL-10 concentrationsand outcome in terms of organ dysfunction 24 h after cardiopulmonarybypass. Methods. Blood samples were obtained from 150 patients before,and 3, and 24 h after cardiopulmonary bypass. IL-10 wasmeasured by enzyme immunoassay. The single nucleotide polymorphismat –1082 base pairs was detected by restriction fragmentlength polymorphism analysis. Post-bypass organ system dysfunctionwas defined prospectively. Results. IL-10 concentrations were increased 3 h afterbypass (P<0.0001) and were still increased at 24 h (P<0.0001).Homozygosity for the G allele was associated with lower median(range) maximal IL-10 levels at 3 h (44 (13–136)pg ml^–1) compared with the A allele (118 (39–472)pg ml^–1; P=0.042). Those patients who developed atleast one organ dysfunction (n=33) had higher IL-10 levels 3 hafter surgery (242 (18–694) pg ml^–1) comparedwith those without organ dysfunction (77 (7–586) pg ml^–1;P=0.001, n=117). Conclusions. The G allele of the –1082 base pair singlenucleotide polymorphism in the IL-10 gene is associated withlower IL-10 release after cardiopulmonary bypass. High levelsof IL-10 secretion are associated with organ dysfunction 24 hafter surgery. Br J Anaesth 2003; 91: 424–6     

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     

Alveolar and serum oxidative stress in ventilator-associated pneumonia

Background. In several lung diseases, oxidative stress can bedemonstrated. This has not been shown in patients with ventilator-associatedpneumonia (VAP). Methods. We studied plasma and bronchoalveolar lavage (BAL)samples for markers of oxidative stress, taken from patientswith VAP. Seventy-eight patients likely to have VAP and 10 patientswho were not suspected of having VAP were studied prospectively.A diagnosis of VAP was based on a positive quantitative mini-lavageculture of     

Concentration of rocuronium in cerebrospinal fluid of patients undergoing cerebral aneurysm clipping

Background. This study assessed the concentration of rocuroniumin the cerebrospinal fluid (CSF) of patients undergoing cerebralaneurysm clipping, and investigated whether the mode of administration(single bolus vs continuous infusion) influenced the CSF concentration. Methods. Twenty patients with subarachnoid haemorrhage wererandomly allocated to receive a bolus dose (bolus group), ora bolus followed by a continuous infusion of rocuronium (infusiongroup) (n=10 for each group). Arterial blood and ventricularCSF were sampled 2 h after the rocuronium bolus. Samples wereanalysed by liquid chromatography electrospray ionization-tandemmass spectrometry. Results. Rocuronium could be detected in all the CSF samples.The mean (range) CSF concentration was 2.2 (0.9–4.6) ngml^–1 in the bolus group and 12.4 (2.4–34.6) ng ml^–1in the infusion group; P<0.01. Conclusions. This study demonstrated that rocuronium, normallynot considered to cross the blood–brain barrier, is regularlyfound in the CSF of patients undergoing cerebral clipping; continuousinfusion of the drug led to higher plasma and CSF concentrationsthan after a single bolus dose. Br J Anaesth 2004; 92: 419–21     

Antagonism of neuromuscular blockade but not muscle relaxation affects depth of anaesthesia

Background. Conflicting effects of neuromuscular blocking drugsand anticholinesterases on depth of anaesthesia have been reported.Therefore we evaluated the effect of atracurium and neostigmineon bispectral index (BIS) and middle-latency auditory evokedpotentials (AAI). Methods. We studied 40 patients (ASA I–II) aged 18–69yr. General anaesthesia consisted of propofol and remifentanilby target-controlled infusion and neuromuscular function wasmonitored by electromyography. When BIS reached stable values,patients were randomly assigned to one of two groups. Group1 received atracurium 0.4 mg kg^–1 and, 5 min later, thesame volume of NaCl 0.9%; group 2 received saline first andthen atracurium. When the first twitch of a train of four reached10% of control intensity, patients were again randomized: onegroup (N) received neostigmine 0.04 mg kg^–1 and glycopyrrolate0.01 mg kg^–1, and the control group (G) received onlyglycopyrrolate. Results. Injection of atracurium or NaCl 0.9% had no effecton BIS or AAI. After neostigmine–glycopyrrolate, BIS andAAI increased significantly (mean maximal change of BIS 7.1[SD 7.5], P<0.001; mean maximal change of AAI 9.7 [10.5],P<0.001). When glycopyrrolate was injected alone BIS andAAI also increased (mean maximal change of BIS 2.2 [3.4], P=0.008;mean maximal change of AAI 3.5 [5.7], P=0.012), but this increasewas significantly less than in group N (P=0.012 for BIS; P=0.027for AAI). Conclusion. These data suggest that neostigmine alters the stateof propofol–remifentanil anaesthesia and may enhance recovery.     

Optimal concentration of epidural fentanyl in bupivacaine 0.1% after thoracotomy

Background. The aim of this prospective, double-blind, randomizedcontrolled trial was to investigate the analgesic and adverseeffects of three commonly used concentrations of thoracic epiduralfentanyl with bupivacaine in patients undergoing thoracotomyfor lung resection. Methods. We studied 99 patients who were randomized to receivefentanyl 2 µg ml^–1 (group 2), fentanyl 5 µgml^–1 (group 5) and fentanyl 10 µg ml^–1 (group10) in bupivacaine 0.1% via a thoracic epidural. Postoperatively,pain on coughing was assessed using a visual analogue scale(VAS) and an observer verbal rating score (OVRS) at 2, 8, 16and 24 h. At the same times, sedation, pruritus and nausea wereassessed. Results. Of 29, 28 and 32 patients who completed the study ingroups 2, 5 and 10 respectively, there was no significant differencein baseline characteristics between the three groups. The numberof patients with episodes of unsatisfactory pain, i.e. VAS scores>30 mm and OVRS >1, at each of the four assessments postoperativelywas significantly (P<0.01) higher in group 2 than in groups5 and 10. In group 10, 16 patients had sedation scores >1compared with 10 each in groups 2 and 5. In addition, 19 patientsin group 10 experienced pruritus compared with 12 each, in groups2 and 5. These differences were not significant. Nausea wasnot significantly different between the three groups. Conclusion. We conclude that thoracic epidural fentanyl 5 µgml^–1 with bupivacaine 0.1% provides the optimum balancebetween pain relief and side effects following thoracotomy. Br J Anaesth 2004: 92: 670–4     

How safe is hand-assisted laparoscopic donor nephrectomy?--Results of 200 live donor nephrectomies by two different techniques

Background. Despite the rapid introduction of laparoscopic livingdonor nephrectomy, doubts exist about safety compared with opensurgery. Early series have often reported on selective donorgroups. We present a consecutive, prospective analysis of morbidityfollowing hand-assisted laparoscopic donor nephrectomy (HALDN)compared with historical controls undergoing open donation (ODN)in a total of 200 living donors at a single UK centre. Methods. The results of 144 consecutively performed HALDN donorswere compared to 56 preceding ODN patients. Patients with multiplearteries, right-sided nephrectomies and obesity were included.Data on recovery and complications were collected prospectivelyand consecutively. Results. There were two (1.4%) major complications in the HALDNgroup and one in the ODN group (1.8%, P = 0.629). Additionally,there were 24 minor complications in 23 HADLN patients (16.7%),compared with 21 in 21 ODN patients (37.5%, P = 0.003). Timetaken to return to normal activity and mean post-operative staywas significantly shorter for the HALDN group. There was nomortality in either group. Conclusions. Contrary to concerns, we report a safe experiencewith HALDN with a low rate of major complications. Furthermore,our patients spend less time in hospital with an earlier returnto normal activity compared with open donation.     

Randomized double-blind clinical trial comparing topical and sub-Tenon's anaesthesia in routine cataract surgery

Background. Several local anaesthetic techniques are availablefor cataract surgery. Recently, topical anaesthesia has gainedin popularity. A randomized trial was designed to compare patientdiscomfort and intraoperative complications following routinecataract surgery under topical or sub-Tenon's anaesthesia. Methods. A randomized double-blinded placebo-controlled clinicaltrial of 210 patients assigned to either a sub-Tenon's group(sub-Tenon's anaesthesia with placebo topical balanced saltsolution, n=140) or a topical anaesthesia group (topical anaesthesiawith placebo sub-Tenon's injection of balanced salt solution,n=70) was carried out. All patients underwent phacoemulsificationwith intraocular lens implantation. Patients in the sub-Tenon'sgroup received a single injection (3 ml) of a combination oflidocaine 2% (2 ml) and bupivacaine 0.75% (1 ml), and four dosesof topical placebo (balanced salt solution). Patients in thetopical anaesthesia group received four doses of topical proxymethocaine0.5% and a placebo sub-Tenon's injection (3 ml) of balancedsalt solution. No intracameral injection of local anaestheticwas given. A 10-point visual analogue pain scale was used preoperativelyand for postoperative pain assessment immediately after theoperation and 30 min postoperatively. The intraoperative complicationsin the two groups were recorded. Results. The mean pain score immediately after surgery was 2.42(SD 2.2) in the sub-Tenon's group and 3.44 (2.3) in the topicalanaesthesia group (P=0.0043). The mean pain score 30 min aftersurgery was 1.24 (1.7) in the sub-Tenon's group and 2.25 (2.2)in the topical anaesthesia group (P=0.0009). Conclusions. Patients undergoing cataract surgery under topicalanaesthesia experience more postoperative discomfort than patientsreceiving sub-Tenon's anaesthesia. Surgery-related complicationswere similar in both groups.