A pain service for children

The development of an acute pain service has enabled hospital staff to improve postoperative analgesia. Patient protocols have been coordinated to ensure consistent and safe management throughout the hospital. Patient satisfaction has been very high with consistently over 90% of patients having good pain relief. High quality analgesia highlights side effects especially urinary retention with extradural opioids. Further research is needed to diminish the incidence of these complications.     

Effects of Surgical Sympathectomy on Skin Blood Flow in a Rat Model of Chronic Limb Ischemia

p < 0.05), NSBF ( p < 0.05), and SO ( p < 0.05) were found to be drastically reduced at day 2 after ligation compared to preligation values. This reduction partially recovered during the following weeks. TSBF ( p < 0.05) and NSBF ( p < 0.05), however were still reduced at day 28 after ligation compared to preligation values, whereas the SO at this time tended to be lower ( p = 0.11). In the sympathectomy group the TSBF was found to be increased at day 2 ( p < 0.05) and day 28 ( p < 0.05) after sympathectomy, both compared to values obtained at day 28 after ligation. Sympathectomy did not have an effect on NSBF and SO. The sham procedure had no effect on the TSBF, NSBF, or SO. These results indicate that in case of lower limb ischemia, sympathectomy improves skin blood flow at the thermoregulatory but not the nutritive level of skin microcirculation. This may be related to the fact that the thermoregulatory vessels are mainly sympathetically controlled, whereas the nutritive capillaries are mainly controlled by local (nonneural) factors.     

Spontaneous echocardiographic contrast within an unruptured sinus of Valsalva aneurysm: A potential embolic source diagnosed by transesophageal echocardiography

A 75-year-old male patient had an unexplained transient ischemic attack. Transesophageal echocardiography revealed a large, unruptured Sinus of Valsalva aneurysm which contained spontaneous echo contrast. This finding represents a potential source of embolism.     

Advance Directives in the Emergency Department: Too Few, Too Late

Objective: To determine: 1) the number of patients arriving at the ED who had executed an advance directive (AD), 2) how many of the patients who had an AD brought the AD with them, and 3) whether those patients who did not have an AD had ever discussed ADs with their primary care providers (PCPs) or had ever heard of an AD.
Methods: A cross-sectional, observational survey of a convenience sample of high-risk patients presenting to the ED of a university hospital was performed. Patients presenting to the ED for acute complaints who were elderly or had an underlying disease that suggested a risk of death in the near future were considered high risk.
Results: Of the 238 patients surveyed, 90% had PCPs. However, only 22% had ADs. Of these, only 23% brought the AD to the ED. Of the patients who did not have ADs, 95% had never discussed ADs with their PCPs, and 42% did not know what an AD was. Blacks were less likely than whites to have ADs (p < 0.0002) or to know about them (p < 0.004).
Conclusion: The majority of high-risk patients presenting to this ED do not have ADs. Among those high-risk patients who did have ADs, fewer than 25% brought the ADs with them. The development of ADs for high-risk patients and the availability of ADs in the ED are woefully inadequate. Emergency physicians need to collaborate with PCPs to remedy these deficiencies.     

Effects of Combining Propofol and Alfentanil on Ventilation, Analgesia, Sedation, and Emesis in Human Volunteers

Background: Propofol and alfentanil frequently are administered together for intravenous sedation. This study investigated pharmacokinetic and pharmacodynamic interactions between propofol and alfentanil, at sedative concentrations, with specific regard to effects on ventilation, analgesia, sedation, and nausea.

Methods: Ten male volunteers underwent steady-state infusions on 3 separate days consisting of propofol alone, alfentanil alone, or a combination of the two. Target plasma concentrations for propofol were 150, 300, and 600 ng/ml for 1 h at each concentration; for alfentanil it was 40 ng/ml for 3 h. Assessment included serial measurements of (1) ventilatory function (minute ventilation, carbon dioxide production, end-tidal carbon dioxide, ventilatory response to rebreathing 7% CO2); (2) analgesia (subjective pain report in response to graded finger shock and evoked potential amplitude); (3) sedation (subjective rating, observer scores, and digit symbol substitution test); (4) nausea (visual analog scale, 0-100 mm).

Results: During combination treatment, propofol plasma concentration was 22% greater than during propofol alone using replicate infusion schemes (P < 0.009). End-tidal carbon dioxide was unchanged by propofol, and increased equally by alfentanil and alfentanil/propofol combined (Delta end-tidal carbon dioxide 7.5 and 6.2 mmHg, respectively). Analgesia with propofol/alfentanil combined was greater than with alfentanil alone. (Pain report decreased 50% by PA vs. 28% for alfentanil, P < 0.05). Sedation was greater with propofol/alfentanil combined than with alfentanil or propofol alone (digit symbol substitution test 30 for propofol/alfentanil combined vs. 57 for alfentanil, and 46 for propofol, P < 0.05). Nausea occurred in 50% of subjects during alfentanil, but in none during propofol/alfentanil combination treatment.     

Anaesthetic management of the Kenny-Caffey syndrome using the laryngeal mask

We report the anaesthetic management of a nine-year-old, 6.8 kg, 75 cm tall female with the Kenny-Caffey syndrome presenting for strabismus surgery. Dysmorphic features in our patient included a hypoplastic mandible. A neonatal (size 1) laryngeal mask was successfully used for management of the airway whilst providing surgical access. The general features of this rare syndrome are presented and the literature reviewed.     

Accuracy of microcentrifuged hematocrits in the emergency department

This study tests whether hematocrits (Hcts) can be accurately measured in an emergency department by microcentrifuge technique. Prior to obtaining the results of a laboratory Hct (LAB Hct), microcentrifuged Hcts (MC Hcts) were determined on 204 emergency department patients. The average difference for LAB Hct - MC Hct was −0.539 ± 1.64 (SD). The 95% confidence interval was (−0.76, −0.31) for the difference scores and (1.49, 1.81) for the SD. The two techniques had excellent correlation (r = 0.96). Plotting the MC Hct against the LAB Hct produced a line of best fit that essentially passed through the origin (Y INTERCEPT = 0.31) and had a slope of 1.006 (both t's < 1). When only the Hct is desired, MC Hcts can be performed in place of LAB Hcts without compromising accuracy.