My 70 year old mother suddenly had more than her fair share of ill luck A cataract operation was complicated by postoperative pain, and bad dreams brought on by the opiate analgesia. Then a bus rammed into the car in which she was a restrained front seat passenger. Luckily she escaped with only posterior fractures of four ribs. She was admitted to the local district general hospital and it was decided to manage her chest pain by a continuous intravenous infusion of fentanyl. After four days in the …

We studied 60 children, aged 12 months to 8 yr, undergoing plastic surgery under general anaesthesia supplemented by regional anaesthesia. Patients were allocated randomly to have the laryngeal mask airway removed either on awakening or while anaesthetized. Subsequent observation of respiratory factors and oxygen saturation showed a significant difference between the groups for coughing (P < 0.001), with a greater incidence (17 of 33) in the awake group compared with those from whom the laryngeal mask airway was removed while anaesthetized (two of 27). There were no differences in the incidences of laryngospasm, desaturation (< 95%) and excess salivation between the groups. Removed of the laryngeal mask airway during deep anaesthesia reduced coughing in the immediate postoperative period.

We have investigated the possibility of using the pre-operative measurement of cholinesterase activity to predict the postoperative development of myalgia following the administration of suxamethonium. Seventy-seven patients presenting for elective extraction of wisdom teeth were entered in the study. All patients received a standard anaesthetic regimen, including suxamethonium to facilitate tracheal intubation, and standardised postoperative analgesia. Myalgia was assessed postoperatively and no correlation between muscle pains and cholinesterase activity was found.

Pulse oximetry is a powerful tool for patient monitoring but there are practical problems with its application in small children. Standard probes may be too large to be used easily and dedicated paediatric probes may be awkward to apply. The authors describe a modification of the Nellcor 'Oxiband' probe which simplifies its use in children. The modified probe was compared in 27 children with the conventional 'clothes-peg' type of device and found to under-read by 1.5% with 95% confidence intervals of +/- 3.1%. This is comparable to the error of the 'Oxiband' probe in normal use of +/- 3% over the range of saturations 70-95%. It is concluded that the modified probe may safely be used in clinical practice.

We have studied 42 female patients undergoing elective day-case surgery allocated randomly to two groups. After induction of anaesthesia an attempt was made to insert a laryngeal mask airway after application of cricoid pressure in one group or with no cricoid pressure in the other. The anaesthetist was unaware of the application, or not, of cricoid pressure. Successful insertion was achieved at the first or second attempt in 19 of the 22 patients in the non-cricoid pressure group, but in only three of the 20 patients in the cricoid pressure group (chi 2 18.62, P < 0.001). The laryngeal mask airway was then inserted successfully in all 17 patients after removal of cricoid pressure. The implications of having to remove cricoid pressure if a laryngeal mask airway is to be inserted are discussed.

SummaryNinety patients who presented for elective gynaecological laparoscopy as day cases were allocated at random to three groups and studied on a double blind basis to compare the effects of nizatidine, ranitidine or placebo on gastric secretion. All the patients received the active drugs or placebo orally at least 45 minutes before the induction of anaesthesia. After tracheal intubation gastric fluid was aspirated via an orogastric tube and the volume and pH of the aspirate were measured. Venous blood samples were obtained at the times of gastric sampling to determine the plasma levels of the drugs. The proportion of patients with both pH > 2.5 and volume < 25 ml were 100%, 90%, and 92.9% in the nizatidine, ranitidine and placebo groups respectively. There was no difference in volume between groups. Two patients in the nizatidine group without a measurable aspirate had blood levels less than the therapeutic range. The median pH values in both treated groups were significantly greater than in the placebo group, but there were no differences between the two treated groups. There were 19 (67.8%) patients in the placebo group with pH < 2.5. This was significantly higher than the 2 (7.4%) and 6 (20%) in the nizatidine and ranitidine groups respectively. When the time interval between drug administration and induction of anaesthesia was divided arbitrarily into 45‐90 minutes and > 90 minutes, all the patients in the nizatidine and ranitidine groups with pH < 2.5 were given the drugs in the 45–90 minute interval; this suggests a latent period is required before the gastric pH increases. Nizatidine may be an effective protective agent against acid aspiration syndrome.

Summary The effect of intra‐operative fluid and dextrose administration upon recovery was tested in a randomised, double‐blind trial. Three groups of 25 patients, each undergoing laparoscopic examination as day cases, were studied. The two groups who received fluid (20 ml/kg compound sodium lactate solution) showed significant improvement (p < 0.05) in the variables that reflected hydration. The fluid group who also received dextrose (1 g/kg) exhibited further significant improvement. Intra‐operative fluid and dextrose administration appears to confer some benefit upon recovery in patients who have minor surgery.

AnaesthesiaVolume 44, Issue 10 p. 860-861 Free Access Is halothane obsolete? Two standards of judgement C. E. Blogg, C. E. Blogg The Radcliffe Infirmary, Oxford OX2 6HESearch for more papers by this author C. E. Blogg, C. E. Blogg The Radcliffe Infirmary, Oxford OX2 6HESearch for more papers by this author First published: October 1989 https://doi.org/10.1111/j.1365-2044.1989.tb09111.xCitations: 1 All correspondence should be addressed to Dr J. N. Lunn, Editor of Anaesthesia, Department of Anaesthetics, University Hospital of Wales, Heath Park, Cardiff CF4 4XW, United Kingdom. Letters must be typewritten on one side of the paper only and double spaced with wide margins. Copy should be prepared in the usual style and format of the Correspondence section. Authors must follow the advice about references and other matters contained in the Notice to Contributors to Anaeslhesia printed at the back of each issue. The degrees and diplomas of each author must be given in a covering letter personally signed by all the authors. Correspondence presented in any other style or format may be the subject of considerable delay and may be returned to the author for revision. If the letter comments on a published article in Anaesthesia, please send three copies; otherwise IWO copies of your leiier will sufice. AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1 Weis KH, Engelhardt W. Halothan obsolet. [übersichten] Ein Beispiel für Messen mit zweierlei Mass. Der Anaesthesist 1987; 36: 315–20. Is halothane obsolete? An illustration of measurement with two standards (English title.). CASPubMedWeb of Science®Google Scholar 2 Williams R. Halothane and the liver–A medical review. In: FE Bennetts, ed. Halothane and the liver. The problem revisited. Proceedings of a symposium at Bristol University Medical 1986: 12–9. Google Scholar 3 Buck N, Devlin HB, Lunn JN. The report of a confidential enquiry into perioperative deaths. London : Nuffield Provincial Hospitals Trust, 1987. Google Scholar 4 Vercani D, Mieli-Vergani G, Alberti A, Neubercer J, Eddleston ALWF, Davis M, Williams R. Antibodies to the surface of halothane–altered rabbit hepatocytes in patients with severe halothane-associated hepatitis. New England Journal of Medicine 1980; 303: 66–71. 10.1056/NEJM198007103030202 PubMedWeb of Science®Google Scholar 5 Neuberger J, Williams R. Halothane anaesthesia and liver damage. British Medical Journal 1984; 289: 1136–9. 10.1136/bmj.289.6452.1136 CASPubMedWeb of Science®Google Scholar 6 Benjamin SB, Goodman ZD, Ishak KG, Zimmerman HJ, Irey NS. The morphological spectrum of halothane-induced hepatic injury: analysis of 77 cases. Hepatology 1985; 5: 1163–71. 10.1002/hep.1840050617 PubMedGoogle Scholar 7 Whitburn RH, Sumner E. Halothane hepatitis in an 11-month-old child. Anaesthesia 1986; 41: 611–3. 10.1111/j.1365-2044.1986.tb13053.x CASPubMedWeb of Science®Google Scholar 8 Trowell J, Peto R, Smith AC. Controlled trial of repeated halothane anaesthetics in patients with carcinoma of the uterine cervix treated with radium. Lancet 1975; 1: 821–4. 10.1016/S0140-6736(75)93001-9 PubMedWeb of Science®Google Scholar 9 Wright R, Eade OE, Chisholm M, Hawksley M, Lloyd B, Moles TM, Edwards JC, Gardner MJ. Controlled prospective study of the effect on liver function of multiple exposures of halothane. Lancet 1975; 1: 817–20. 10.1016/S0140-6736(75)93000-7 PubMedWeb of Science®Google Scholar 10 Zaric D, Larsen SF, Jacobsen E, Olesen KH, Ranek L. Halothane hepatitis in a prospective study of postoperative complications. Acta Anaesthesiologica Scandinavica 1986; 30: 529–32. 10.1111/j.1399-6576.1986.tb02469.x CASPubMedWeb of Science®Google Scholar 11 Allan LG, Hussey AJ, Howie J, Beckett GJ, Smith AF, Hayes JD, Drummond GB. Hepatic glutathione S-transferase release after halothane anaesthesia: open randomised comparison with isoflurane. Lancet 1987; 1: 771–4. 10.1016/S0140-6736(87)92799-1 CASPubMedWeb of Science®Google Scholar 12 Fee JPH, Black GW, Dundee JW, McIlroy PDA, Johnston HML, Johnston SB, Black IHC, McNeill HG, Neill DW, Dogcart JR, Merrett JD, McDonald JR, Bradley DSG, Haire M, McMillan SA. A prospective study of liver enzyme and other changes following repeat administration of halothane and enflurane. British Journal of Anaesthesia 1979; 51: 1133–41. 10.1093/bja/51.12.1133 CASPubMedWeb of Science®Google Scholar 13 Blogg CE, Sear JW, Dunnet J, Brighouse D. Toxicity of repeat isoflurane? A preliminary report. In: P Lawin, H Van Aken, C Puchstein, eds. Isoflurane. London : Springer-Verlag, 1986: 32–6. 10.1007/978-3-642-71230-2_6 Google Scholar Citing Literature Volume44, Issue10October 1989Pages 860-861 ReferencesRelatedInformation

AnaesthesiaVolume 43, Issue 2 p. 169-169 Free Access Inspired monitoring I. Sivakoluntho, I. Sivakoluntho The Radcliffe Infirmary, Oxford OX2 6HESearch for more papers by this authorC.E. Blogg, C.E. Blogg The Radcliffe Infirmary, Oxford OX2 6HESearch for more papers by this author I. Sivakoluntho, I. Sivakoluntho The Radcliffe Infirmary, Oxford OX2 6HESearch for more papers by this authorC.E. Blogg, C.E. Blogg The Radcliffe Infirmary, Oxford OX2 6HESearch for more papers by this author First published: February 1988 https://doi.org/10.1111/j.1365-2044.1988.tb05522.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1 Mathias JA, Lunn JN. Minimal monitoring and vigilance. Anaesthesia 1987; 42: 683– 4. 2 Sykes MK. Essential monitoring. British Journal of Anaesthesia 1987; 59: 901– 12. Volume43, Issue2February 1988Pages 169-169 ReferencesRelatedInformation

A simple system for closed-loop control of neuromuscular blockade is described. It comprises a Datex Relaxograph, a small relay and a syringe pump. The equipment is commercially available and requires no complex custom-built electronics. Atracurium was infused in a semicontinuous manner to 11 patients who underwent general anaesthesia for a variety of surgical procedures. Neuromuscular blockade oscillated within a narrow range around the preset level. The mean rate of infusion of atracurium was 0.5 mg/kg/hour (SD 0.13). The mean recovery time was 25.5 minutes (SD 7.95).

SummaryForty‐two patients, undergoing major gynaecological surgery, were randomly allocated to have a patch applied to the skin behind one ear, containing either hyoscine or placebo. They were followed up at 24‐hour significant (p < 0.01) reduction in nausea and vomiting in the first 24 hours postoperatively, but no difference thereafter. There was an increased incidence of visual disturbance in the hyoscine group at 48 hours. but no other differences in the side effects studied at any other time. However, despite receiving hyoscine there was still a high incidence (68%) of severe nausea and vomiting.

A randomised, double blind study, of 58 female patients undergoing laparoscopic investigation was carried out to compare triazolam 0.25 mg, lorazepam 2 mg, or placebo as oral premedication. Each patient was assessed by only one of the authors both pre- and postoperatively with regard to anxiolysis, sedation and rapidity of recovery. Triazolam and lorazepam were each associated with a significant reduction in anxiety compared to the initial assessment, whereas placebo had no anxiolytic effect. Sixty minutes after premedication, patients who had received triazolam were significantly more sleepy than patients given placebo or lorazepam. Two hours after the operation, the patients who had had triazolam or lorazepam were significantly more sleepy than those who received placebo. However, at 6 hours postoperatively there was no difference between triazolam and placebo, whilst those who had been given lorazepam were still significantly more sleepy than those given placebo. Triazolam appears to offer advantages over either lorazepam or placebo in patients who require rapid recovery, sedation and reduction in pre-operative anxiety.

The problem ofhalothane and the liver does exist. Experience in Bristol of two bizarre cases of "halothane hepatitis" led Dr Brian Williams to organise a symposium on the subject earlier this year. His survey of anaesthetists in the South Western Region showed a high level (97%) of awareness of the possibility of hepatitis associated with halothane. The reported incidence ranges from one in 10000 to one in 35 000 anaesthetics in adults. The consensus seemed to be that repeated halothane anaesthesia was an important aetiological factor: of those who replied, three quarters let at least an arbitrary three months elapse before choosing to repeat the use of halothane, while two fifths required a minimum interval of six months. The problem may be preventable. Dr Roger Williams described 48 patients (38 of whom died) who had been referred to the liver unit at King's College Hospital, London, from January 1965 to December 1983'; he gave details of a further eight patients admitted since then. Fewer patients might have been seen had note been taken of exposure to halothane within 26 days-and especially when the first anaesthetic had been followed by the non-specific sign of late onset fever.' Other diagnoses such as non-A non-B hepatitis were impossible to exclude completely, but strong evidence that the patients had halothane hepatitis was provided by a relatively specific test based on sensitised rabbit hepatocytes; this was positive in 16 of 24 patients with liver failure associated with halothane.2 The pattern of the problem has also changed.3 Dr Williams referred to five cases among children, one ofwhom had died. It seems that the adult population may be divided into three groups: most may probably be given halothane with impunity -but that has to be a retrospective assessment. Up to one fifth respond on close repeated exposure to halothane with a mild rise in their transaminase activities and some prolongation of the prothrombin time. The remaining few develop jaundice, grossly raised activities of aspartate aminotransferase, encephalopathy in half, and rapidly progressive liver failure. No effective treatment has been found other than the hope of urgent liver transplantation. Whether or not halothane hepatitis can be induced in animals is still not clear. Rats consistently develop a similar syndrome only when they are hypoxic, starved, male, and

Hepatitis related to halothane has been found to follow about 1 in 35000 halothane anaesthesia [1]. One of the most important factors in unexplained hepatitis following halothane (UHFH) is repeated exposure to halothane within a short period, and the results of the investigation of a prospective series of patients undergoing radium implantation in Oxford in 1973–1974 appeared to confirm the association [2]. Subsequently, there has been extreme reluctance to repeat the use of halothane for anaesthesia within a few weeks (especially in middle-aged, obese women being treated for carcinoma of the cervix), despite other reports which show lack of adverse hepatic effects [3, 4].

One hundred patients were allocated randomly to pretreatment with atracurium 2.5 mg, atracurium 5 mg, fazadinium 3.75 mg or saline 3 minutes before the injection of suxamethonium. The effect upon neuromuscular conduction was studied by recording the mechanical response of the adductor pollicis muscle to indirect stimulation of the ulnar nerve using repeated 2 Hz train of four stimuli. Blood samples were taken at intervals for the measurement of serum potassium. There was no significant difference in the incidence of postoperative muscle pains between the groups in the first 72 hours following anaesthesia. The use of the larger pretreatment dose of atracurium resulted in clinically significant neuromuscular blockade in three of the subjects. Minimal changes in serum potassium occurred in all patients but there was no statistical difference between the groups.

Summary Many solutions have been proposed for achieving tracheal intubation in patients with anatomical abnormalities which preclude the conventional use of a laryngoscope. The use of a guide passed in a retrograde direction into the mouth via the larynx (Waters, 1963) or trachea (Ramsay and Salyer, 1981) has proved useful by allowing the tracheal tube to be guided over the guide from the mouth or nose into the larynx. Greater control is achieved by the use of a relatively rigid wire (Ramsay and Salyer, 1981; Roberts, 1981; McLean, 1982) but passage of the tube into the trachea is impeded by the guide protruding through the skin of the neck. If the guide is removed, the risk of displacing the tracheal tube as it is advanced is increased.

AnaesthesiaVolume 37, Issue 12 p. 1217-1218 Free Access Rises in serum potassium after suxamethonium following brachial plexus injury N.H. Kay, N.H. Kay Nuffield Department of Anaesthetics, John Radcliffe Hospital, Headington, Oxford OX3 9DUSearch for more papers by this authorC.E. Blogg, C.E. Blogg Nuffield Department of Anaesthetics, John Radcliffe Hospital, Headington, Oxford OX3 9DUSearch for more papers by this author N.H. Kay, N.H. Kay Nuffield Department of Anaesthetics, John Radcliffe Hospital, Headington, Oxford OX3 9DUSearch for more papers by this authorC.E. Blogg, C.E. Blogg Nuffield Department of Anaesthetics, John Radcliffe Hospital, Headington, Oxford OX3 9DUSearch for more papers by this author First published: December 1982 https://doi.org/10.1111/j.1365-2044.1982.tb01797.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. References 1 Gronert GA, Lambert EH, Theye RA. The response of devervated skeletal muscle to succinylcholine. Anesthesiology 1973; 39: 13– 22. 2 Cooperman LH. Succinylcholine induced hyperkalaemia in neuromuscular disease. Journal of the American Medical Association 1970; 213: 1867– 71. 3 Tobey RE, Jacobsen PM, Kahle CT, Clubb RJ, Dean MA. The serum potassium response to muscle relaxants in neural injury. Anesthesioiogy 1972; 37: 332– 7. 4 Paton WDM. The effects of muscle relaxants other than muscular relaxation. Anesthesiology 1959; 20: 453– 63. 5 Bali IM, Dundee JW, Assaf RAE. Immediate dangers in plasma potassium, sodium and chloride concentrations induced by suxamethonium. British Journal of Anaesthesia 1975; 47: 393– 7. 6 Dal Santo, G. Kinetics of distribution of radioactive labelled muscle relaxants III. Investigations with 14c–succinylmonocholine during controlled conditions. Anesthesiology 1968; 29: 435– 43. 7 Lehmann H. Silk E. Succinylmonocholine. British Medical Journal 1953; i: 767. Volume37, Issue12December 1982Pages 1217-1218 ReferencesRelatedInformation