Barotrauma due to obstruction of the breathing system during a CT-scan examination in a child

A case of pulmonary barotrauma is described in a child undergoing a CT scan in the prone position. Anaesthesia was uneventful until the final exiting movement from the scanner when inadvertent total occlusion of the expiratory limb of a Jackson-Rees modification of the Ayre's T-piece occurred. The rapid rise in intrapulmonary pressure caused bilateral pneumothoraces despite the use of an uncuffed tracheal tube. The unusual demands of anaesthesia in the X-ray department may have contributed to this uncommon complication of the use of an Ayre's T-piece.     

Patient controlled analgesia—assessment of machine feedback to patients

The effect of varying patient-controlled analgesia machine feedback was studied in two groups of patients following a standard surgical procedure using patient controlled analgesia with morphine to control postoperative pain. Analgesic demands, morphine consumption, pain scores and side effects were compared and comments from the patients were noted. There was no significant difference between those whose machines signalled only successful demands compared with those who had every demand acknowledged. The patients in the former group appreciated the extra input and the nursing staff found this machine configuration to be less disturbing to the ward. There was no evidence of a clinically useful placebo effect in the latter group.     

Local anaesthetic: does it really reduce the pain of insertion of all sizes of venous cannula?

A recent study performed in this department showed that a subcutaneous injection of local anaesthetic was significantly less painful than the insertion of a 22-gauge venous cannula. However, our colleagues remained sceptical that local anaesthetic infiltration would eliminate the pain of cannulation. Consequently a further study was undertaken to compare the pain of cannulation with and without the use of local anaesthetic. The results show that pain of cannulation is significantly (p < 0.003) reduced after subcutaneous infiltration with 1% lignocaine when compared to cannulation without local infiltration. Persistent discomfort at the site of cannulation was eliminated by the use of local anaesthetic.     

Factors influencing epidural catheter migration

The incidence and amount of migration of epidural catheters was investigated in a prospective randomised study of 153 women who required analgesia in labour. Inward or outward migration occurred in 36% of patients. Inward migration by 1-3 cm occurred in 21 (13.7%) patients and outward migration by 1 cm or more occurred in 34 (22.2%); three (2%) catheters migrated out through the skin. There were significant positive correlations between outward migration and weight, body mass index, and depth of the epidural space. There was no relationship between migration and height, age, intervertebral space used or duration of catheterisation. Problems with epidural block were no more likely in patients in whom migration of 1 cm or more occurred compared with those in whom migration was limited to a maximum of +/- 0.5 cm. However, the pattern of problems was different. All cases of failed epidural block occurred in patients whose epidural catheter migrated outward by 2.5 cm or more. Unilateral blockade was not more likely if migration of 1 cm or more occurred.     

PARANEOPLASTIC PARALYSIS IN A PATIENT WITH MALIGNANT FIBROUS HISTIOCYTOMA

A patient presented with lower limb paralysis and a large malignant fibrous histiocytoma (MFH) on her back. Metastatic disease to the spine was excluded and the diagnosis of paraneoplastic paralysis was made. This may be the first described case of a neuromyopathic paraneoplastic syndrome in malignant fibrous histiocytoma. Tissue culture and electron microscopy assisted in establishing the diagnosis of the tumour. A hitherto unrecognised endocrine factor may account for the hypokalaemia which was a feature in this patient.