Showing papers in "Acta Anaesthesiologica Scandinavica in 1982"

Attenuation of the circulatory response to laryngoscopy and intubation by fentanyl.

Abstract: The effects of fentanyl on arterial pressure and heart rate increases during laryngoscopy and intubation were studied in 45 normotensive, surgical patients, who were randomly allocated to three groups receiving 2 or 6 micrograms/kg of fentanyl or saline in a double-blind fashion before anaesthetic induction with thiopental. Fentanyl supplementation with 2 micrograms/kg significantly attenuated the arterial pressure and heart rate increases during laryngoscopy and intubation, and fentanyl, 6 micrograms/kg, completely abolished these responses. Moreover, fentanyl given during the induction decreased the amount of fentanyl needed during the operation. Respiratory depression was not observed during recovery.

EMLA ‐ a Eutectic Mixture of Local Anaesthetics for Topical Anaesthesia

Abstract: A new topical anaesthetic formulation, EMLA, consisting of a eutectic mixture of the two local anaesthetics, prilocaine and lidocaine, was used in an attempt to reduce the pain associated with venous cannulation in children. The formulation of the local anaesthetic cream yields a high concentration (approximately 80%) of active substance compared with previous formulations (approximately 20%). A highly statistically significant difference in the experience of pain due to venous cannulation in favour of EMLA compared with placebo was found in this study (P less than 0.001) in 60 children from 6 to 15 years of age. Stimulus of C fibre endings in the subcutaneous tissue and/or the vascular wall seems to be the mechanism behind the slight to moderate discomfort experienced by about one third of the children treated with EMLA. Local side effects of EMLA were negligible.

Patient-controlled analgesic therapy: clinical experience.

Abstract: Fifty-six surgical patients self-administered i.v. narcotic analgesics to combat postoperative pain. Analgesic demand per h was 2.7 +/- 1.1 mg of morphine, 26 +/- 10 mg of pethidine or 2.3 +/- 0.8 mg of ketobemidone, which reflects the equianalgesic ratios. Acute respiratory depression was seen in two hypovolaemic patients as evidenced by a raised PaCO2 on air breathing. Carbon dioxide retention disappeared upon correction of hypovolaemia. Late respiratory complications of short duration were encountered in 13%. Drowsiness and dry mouth were the most frequent complaints. Self-administered analgesia was considered highly satisfactory by the patients.

Clinical pharmacokinetics of methadone.

Abstract: Studies with single doses of methadone have shown that the oral biological availability is 79 +/- 21%, range 41-99%. The rate of elimination is mostly due to metabolic clearance. Below a urinary pH of 6, renal clearance becomes of quantitative importance. In five subjects treated with ammonium chloride (acidic urine), the plasma half-life of methadone was found to be 19.5 +/- 3.6 h. When treated with sodium bicarbonate the same subjects had plasma half-lives of 42.1 +/- 8.8 h. During continuous treatment with methadone, cellular tolerance may occur and in some subjects also metabolic tolerance. In treatment of severe cancer pain such adaptive changes in methadone pharmacodynamics and pharmacokinetics are best managed by a regimen involving a fixed dose but a flexible and patient-controlled dosage interval.

Potent, new analgesics, tailor-made for different purposes.

Abstract: There is a variety of conditions linked to intense pain and stress. Some may last for a relatively short period of time, such as certain surgical interventions; others may have a very extended duration. All of these conditions share a common need for potent analgesics that provide sufficient pain relief and alleviation of the stress response. Extensive research in the lield of narcotic analgesics for more than 25 years has led to the development of a series of potent analgesics tailor-made for difrerent purposes.

A comparison of memory function following local and general anaesthesia for extraction of senile cataract.

Abstract: The memory performance of 60 female patients, scheduled for either local or general anaesthesia and extraction of senile cataract, was investigated. Six subtests of the Wechsler Memory Scale and four items of memory tests according to Luria were performed. One week postoperatively there was a diminution in the performance of the Wechsler Memory Scale and Luria tests. Comparison of the pre- and postoperative diminutions between the local and general anaesthesia groups was statistically significant only in the Luria tests. According to this study general anaesthesia does not affect memory function more profoundly than local anaesthesia supplemented with tranquilizing and/or analgesic drugs. In this respect, the advantages of general anesthesia should be utilized, at least in patients without clearcut contraindications.

Methods for measuring clinical pain in humans.

Abstract: The concept of pain being a measurable phenomenon distinct from other sensations had its origins in the pioneering work of Weber and Fechner well over a century ago. However, though pain is virtually a universal experience of mankind, it is uncommonly difficult to define; and progress in expressing its dimensions in quantitative terms has been evident only in relatively recent years. The methods which have evolved have largely reflected the primary interests of the investigator, or therapist, and the clinical setting in which the studies have been made. Although it had long been recognized that pain consists of both cognitive and affective components, most of the earlier systematic investigations focused on measuring the sensory dimensions of pain under conditions which were meant to minimize the reaction component of pain. Large numbers of experimentally induced pain techniques were developed to measure pain thresholds and pain tolerance. Among the leading proponents of this approach were HARDY, WOLFF and GOODELL (HARDY et al. 1952) whose Do1 Scale of Pain Intensity was felt to confirm Fechner’s law. Many of these early studies formed the foundation for the later development of more highly sophisticated psychophysical techniques, but as diagnostic tools and measures of the effectiveness ofdrugs and other methods of controlling clinical pain, they had many shortcomings. Meanwhile, BEECHER (1959), who as an anesthesiologist was more concerned with the measurement ofpain in terms of its relief, questioned the assumption that pain is the same whatever its origin and that the only characteristics of interest are intensity and duration. Echoing WINKLER’S (1952) statement that “a ‘stimulus’ cannot be defined in terms of its own properties alone, since its capacity to evoke responses is determined in part by antecedent events, and by particular experimental arrangements”, BEECHER (1959) felt that conditioning and all the “elaborate mechanism of the reaction component” served to cast doubt that pain thresholds can ever be measures of pure pain perception. He felt that variations of great degree in the reaction part are determined by the significance of the cause of pain, and that the significance of pain controls the field of usefulness for the study of pain of a given origin. Beecher’s major contribution was in establishing scientifically acceptable principles for evaluating the effects of drugs to relieve pain, the emphasis being on achieving objectivity by appropriate experimental designs and controls in the clinical situation. While this approach has had less impact on modern psychometric techniques than have the experimentally induced pain methods, it has, by contrast, proved to be a more reliable means of detecting and assaying clinically effective analgesic drugs.

Monocyte Functions are Depressed during and after Surgery under General Anaesthesia but not under Epidural Anaesthesia

Abstract: Monocyte functions have been investigated in 18 patients undergoing total hip arthroplasty performed under either general anaesthesia or epidural anaesthesia. Serum cortisol increased significantly both per- and postoperatively in the general anaesthesia group compared to minor changes in the epidural group. The spreading of monocytes on plastic surfaces possibly reflects the phagocytic capacity of the cells. This spreading index of monocytes derived from patients operated under epidural anaesthesia and cultured in medium containing autologous serum showed a significant increase per- and postoperatively compared to the spreading index of monocytes from patients operated under general anaesthesia. This difference increased with increasing culture time. The ability of monocytes to induce lysis in malignant cells was reduced to 45% peroperatively in monocytes derived from patients operated under general anaesthesia and cultured in medium containing autologous serum. In the epidural group the lysis was nearly unchanged from the preoperative value, making the difference between the groups highly significant (P less than 0.01). On the first postoperative day, the difference between the groups was less pronounced. The differences in spreading index and cytolytic capacity were not seen when the monocytes were cultured in medium with pooled AB-serum, thus indicating a serum factor responsible for the monocyte depression when the patients were operated under general anaesthesia.

Pharmacokinetic Studies on Atropine with Special Reference to Age

Abstract: Pharmacokinetic studies on atropine were performed in 52 patients under general or spinal anaesthesia. Age had a clinically significant effect on the kinetics of this alkaloid: in children under 2 years of age and in the elderly a prolonged elimination was found. This might explain, partly at least, the higher sensitivity of these age groups to the effects of atropine. Age had no effect on the serum protein binding of this alkaloid. Atropine was found in human CSF after a single i.m. administration, but not after a single i.v. administration. During anaesthesia after i.v. atropine administration, a diminished cardiovascular response was found in the elderly in comparison with healthy adult patients. This indicates changes also at the cholinergic receptor sites in the elderly.

Material Thrombogenicity in Central Venous Catheterization I. A Comparison Between Uncoated and Heparin‐Coated, Long Antebrachial, Polyethylene Catheters

Abstract: In order to evaluate a new method of heparinization, uncoated (22) and heparin-coated (27) central venous polyethylene catheters were inserted in 49 patients via basilic and cephalic veins punctured at the fossa cubiti. The means duration of catheterization was 5.7 (1-11) days. One-third of the patients with heparin-coated catheters, and one sixth with uncoated catheters developed clinical thrombophlebitis, with a maximum incidence between 4 and 8 days after catheterization. A higher risk of developing thrombophlebitis in the first 4 days after catheterization was found in the patients with heparin-coated polyethylene catheters. After 8 days of catheterization, it seems that there is a lower risk of new cases of thrombophlebitis appearing both in patients with uncoated and those with heparin-coated polyethylene catheters. Radiological thrombosis, regardless of duration of catheterization and heparin-coating, was demonstrated in all 22 patients investigated by "pull-out" phlebography. The heparin-coating did not decrease the rate of thrombotic complications. Location of the catheter tip in subclavian veins was associated with a significantly higher incidence of large, parietal thrombi and catheter occlusion than when the tip was situated in anonymous veins, the superior vena cava, or the right atrium. Cannulation by heparin-coated, polyethylene tubing did not reduce the rate of catheter occlusion.

Clinical Predictors of Intraoperative Myocardial Ischemia in Patients with Coronary Artery Disease Undergoing Non‐Cardiac Surgery

Abstract: In order to detect the incidence of myocardial ischemia during the perioperative period and to determine during which situation it occurred, continuous monitoring of the electrocardiogram by the Holter method was used in 51 patients with coronary artery disease who were undergoing a vascular surgical procedure. Clinical parameters measured preoperatively were evaluated as predictors of the occurrence of myocardial ischemia during the perioperative period. Twenty of 51 patients demonstrated 36 episodes of myocardial ischemia, which started in 11 cases during induction. Fourteen of 16 patients with disabling angina pectoris (Class III and IV) developed myocardial ischemia, whereas only six patients out of 35 with Class II or less or no angina experienced peroperative ischemic episodes (P less than 0.001). All the patients without or with only mild angina who experienced perioperative ischemia showed ST-T abnormalities at the preoperative resting electrocardiogram. Our data suggest that the risk of intraoperative myocardial ischemia can be predicted during the preoperative period by the degree of disability exhibited by patients with coronary artery disease.

Perivascular axillary block. I: blockade following 40 ml 1% mepivacaine with adrenaline.

Abstract: Perivascular axillary block was performed on 80 patients by a catheter technique. All patients had a standard dose of 40 ml mepivacaine 1% with adrenaline. Thirty minutes after the injection, the motor and sensory blockade was determined. Eighty-six per cent of the patients had a distinct motor blockade, whereas the remaining 14% had only a slight motor blockade. The sensory blockade was complete in 63%, whereas 37% had lack of analgesia in one or several cutaneous areas. Lack of analgesia was most often found in the cutaneous area of the axillary, musculocutaneous and radial nerves. The frequency of analgesia in the three areas of innervation was analysed with reference to the influence of the age, height and weight of the patient, and of differences in technique: paraesthesias, position of catheter, and unintended puncture of blood vessels. None of these variables seems to be important for the low frequency of analgesia in the three areas of innervation.

Effect of tubocurarine on human soleus and gastrocnemius muscles.

Abstract: The effect of a bolus injection of tubocurarine (0.1-0.13 mg X kg-1 i.v.) was followed in six young male subjects by registration of the rectified smoothed electromyogram (rsEMG) from the m. soleus (71 +/- 5.1 (s.e. mean) % slow twitch muscle fibers) and from the m. gastrocnemius (54 +/- 3.1% slow twitch muscle fibers). Volitional muscle strength was recorded in isometric plantar flexions with the knee fully (0 degrees) extended where m. soleus and m. gastrocnemius both are active, and with the knee bent 90 degrees where m. soleus is dominating force development. During maximal action of the drug, the rsEMG from the soleus muscle was reduced to 30 +/- 4.0% of the control value, while the rsEMG from the gastrocnemius muscle was reduced to 53 +/- 5.2% (P less than 0.01). Muscle strength with the knee extended showed 53 +/- 7.5% force left, while 44 +/- 6.4% of the muscle strength remained when the knee was bent (P less than 0.01). The results suggest that tubocurarine affects human muscles in proportion to their slow twitch muscle fiber content.

Cerebral Blood Flow and Oxygen Uptake in Endotoxic Shock. An Experimental Study in Dogs

Abstract: Cerebral blood flow (CBF), cerebral oxygen uptake (CMRO2) and central haemodynamics in anaesthetized dogs with controlled ventilation were studied at intervals for 2 h following an intravenous injection of E. coli endotoxin, 1.0-1.5 mg/kg. CBF showed a 30% decrease within 15 min after the endotoxin administration, while the arterial blood pressure was still not markedly depressed. Autoregulation to arterial blood pressure changes was maintained during endotoxinaemia and the cerebrovascular reaction to changes in arterial carbon dioxide tension (PaCO2) depressed. Normocapnic animals (PaCO2) greater than or equal to 4.0 kPa) showed an increase in CMRO2 of over 40%, that was obvious 1 h after the administration of endotoxin. The intracranial pressure was decreased with 5 min of the administration of endotoxin irrespective of the prevailing arterial blood pressure. Thereafter, it was raised above the control level. Two hours after endotoxin increased protein concentrations in cerebrospinal fluid were seen, results compatible with blood-brain barrier damage and penetration of other substances; e.g. monoamines released during endotoxinaemia could thus be expected to have a direct influence on both cerebral blood flow and metabolism.

Intravenous benzodiazepines as anaesthetic agents: pharmacokinetics and clinical consequences.

Abstract: Despite extensive and numerous pharmacokinetic studies on benzodiazepines, the published pharmacokinetic data do not adequately explain the clinical differences found between different benzodiazepine derivatives after intravenous administration. Especially, correlations between initial drug responses and distributional changes of the benzodiazepines are limited. However, during the elimination phase some relationships exist between the kinetic and dynamic phenomena. Age, sex, diseases and concomitantly given drugs cause clinically important alterations in the pharmacokinetics of benzodiazepines. Generally these anxiolytics and sedatives should be considered as adjuvants to general anaesthesia, but not primarily as routine induction agents. The major reasons for this limitation are a high variability in drug response, a relatively slow onset of action and long-lasting residual effects. However, benzodiazepines have many important advantages (see Table 5) when used as intravenous inducing agents of general anaesthesia.

Oxygen uptake, plasma catecholamines and cardiac output during neurolept-nitrous oxide and halothane anaesthesias.

Abstract: Cardiac output, oxygen uptake and plasma catecholamines were studied in patients both awake and during anaesthesia prior to and during upper abdominal surgery. Two different forms of anaesthesia were used: neurolept-nitrous oxide (NLA) and halothane (HALO) anaesthesia. Oxygen uptake was determined by using a masspectrometer, and cardiac output was measured according to the Fick principle. Plasma catecholamines were analysed by high performance liquid chromatography. Cardiac output fell by 40% during NLA and by 30% during HALO. Concomitantly, the oxygen uptake fell by 40% and 35%, respectively. A linear relationship between cardiac output and oxygen uptake could be established both in the awake state and during anaesthesia, with no significant change in the slope or position of the regression line when anaesthesia was commenced. Ventricular filling pressures fell during both anaesthetic procedures. Adrenaline fell to half the plasma concentrations seen in normal subjects under resting conditions, while noradrenaline returned to normal from an initially 30-40% increased value. Surgery caused no significant changes in either cardiac output or oxygen uptake, whereas plasma adrenaline increased by 20 times and noradrenaline by 60-90%. The findings suggest that the reduced oxygen uptake during anaesthesia causes the fall in cardiac output rather than any cardiodepressant action of the anaesthetic. It is possible that the anaesthetic depresses whole-body metabolism by either blocking the effects of catecholamines or interfering with cellular metabolism.

Spinal anaesthesia with hyperbaric 0.5% bupivacaine: effects of volume.

Abstract: Different volumes (1.5, 2, 3 and 4 ml) of hyperbaric 0,5% bupivacaine (8% glucose) were compared in spinal anaesthesia for urological surgery in 40 patients. The blockade was given with the patient in the sitting position. Two minutes after the injection the patient was placed in the lithotomy position. The time required for maximum cephalad spread of analgesia was about 20 min for all volumes. The maximum cephalad spread was directly related to log volume of the local anaesthetic solution. The onset time for motor blockade of the lower limbs decreased and the frequency increased with increasing volume. Four ml produced complete blockade in all patients. The duration of analgesia increased with increasing volume: 3–4 ml produced analgesia at T8 for 1.5-2.5 h and at L1 for 2–3 h. With this volume, complete motor blockade was obtained for 1.5-2.5 h. Satisfactory surgical anaesthesia for transurethral resection was obtained with 3–4 ml of the local anaesthetic solution.

Cardiovascular Effects of High-Dose Fentanyl Anaesthesia

Abstract: An anaesthetic technique using high-dose fentanyl for coronary artery surgery is described. Fentanyl 60 or 70 micrograms kg-1 was used as the sole anaesthetic agent, and patients were ventilated with air/O2 (fentanyl 70 micrograms kg-1) or N2O/O2 (fentanyl 60 micrograms kg-1). Cardiovascular data from 30 patients are presented. Fentanyl caused no significant cardiovascular depression. The only statistically significant changes in cardiovascular parameters were seen in the patients who received fentanyl 60 micrograms kg-1. Five minutes after skin incision there was an increase in peripheral resistance. Diastolic pressure was increased following sternotomy. Problems associated with this technique of anaesthesia are a 50% incidence of hypertension following sternotomy (requiring treatment with sodium nitroprusside) and prolonged respiratory depression. The lack of cardiovascular depression produced by fentanyl and the ability of fentanyl to reduce hormonal and metabolic responses to surgery make it a satisfactory technique for cardiac anaesthesia.

Pentobarbital Plasma Concentrations and Cardiac Electrophysiology During Prolonged Pentobarbital Infusion Anaesthesia in the Dog

Abstract: There is need for a prolonged stable level of anaesthesia, and we therefore investigated the cardiac electrophysiological effects of continuous pentobarbital infusion after initial pentobarbital injection to induce anaesthesia in dogs. Plasma concentrations of pentobarbital were measured by gas-liquid chromatography. Heart rate, atrial, atrioventricular (AV) nodal and His-Purkinje conduction times were measured by His bundle electrography, and atrial, AV nodal and ventricular refractoriness by programmed electrical stimulation. Over a 5-h observation period, continuous infusion of pentobarbital 3.5 mg X kg-1 X h-1 after an initial pentobarbital injection of 25 mg X kg-1 intravenously gave stable mean plasma concentrations of 140-135 mumol X 1(-1). The cardiac electrophysiological variables studied did not change significantly during this period. We conclude that a stable experimental model for cardiac electrophysiological studies can be obtained for several hours by continuous pentobarbital infusion.

Anesthetic techniques and surgical blood loss in total hip arthroplasty.

Abstract: Blood loss during total hip arthroplasty and the relation of different anesthetic techniques to surgical bleeding was explored in a consecutive, prospective study involving 157 patients with no previous history of hip surgery. Intraoperative blood loss was significantly reduced in patients operated under sodium nitroprusside induced hypotensive anesthesia as compared to halothane, NLA or epidural block. It might be suspected that postoperative blood loss is increased when the lowered blood pressure is raised towards normotension, but this was not the case. However, regression analysis between mean arterial pressure and intraoperative blood loss in patients anesthetized with hypotensive as well as "normotensive" techniques showed a poor correlation. Blood loss was greater with NLA and halothane anesthesia than with epidural block. The authors consider controlled hypotension a useful adjuvant in anesthesia for total hip arthroplasty in selected patients. Epidural block, on the other hand, is a suitable anesthetic technique for most patients and has the additional advantage of reduced surgical bleeding as compared to general anesthesia.

Influence of Epidural Morphine on Postoperative Pain, Endocrine‐Metabolic, and Renal Responses to Surgery. A Controlled Study

Abstract: In order to assess the analgesic properties of epidural low-dose morphine and its possible influence on thr adrenocortical, hyperglycemic, renal, electrolyte and leukocyte responses to surgery and nitrogen excretion, a double-blind randomized study was undertaken in 14 otherwise healthy patients admitted lor hysterectomy under halothane, N2O/O2 anesthesia. Before induction of anesthesia, an epidural catheter was introduced into the lumbar epidural space. After induction of anesthesia, either morphine 4 mg in 10 ml saline or 10 ml saline was injected into the epidural space, according to the allocation. Postoperatively, the degree of pain was evaluated by means of a visual analogue scale (0–10). When pain score exceeded 5 points during the 24-h trial, either 4 mg morphine in saline or saline was given epidurally. If the pain score did not decrease more than 2 points after an epidural injection, morphine was given parenterally (5 mg i.v. f 5 mg i.m.). The results showed that pain scores, duration of pain relief and doses of morphine differed significantly between groups (P<0.05). Plasma concentrations of cortisol and glucose, plasma- and urine electrolytes, 24-h creatinine and free-water clearances, diuresis, fluid balance, leukocyte count and nitrogen excretion differed insignificantly between groups. In conclusion, epidural low-dose morphine is a superior alternative to conventional postoperative pain treatment because of greater and longer lasting pain relief, without apparent side-effects. The measured endocrine-metabolic and renal responses did not differ between groups, indicating that low-dose epidural morphine does not inhibit afferent neurogenic stimuli from the site of surgical trauma.

Effects of halothane on coronary haemodynamics and myocardial metabolism in patients with ischaemic heart disease and heart failure.

Abstract: Halothane was administered at an end-tidal concentration of 1% to 10 patients with stable ischaemic heart disease and clinical and haemodymanic signs of moderate heart failure. Measurements of cent ...

Droperidol (Dehydrobenzperidol): postoperative anti-emetic effect when given intravenously to gynaecological patients.

Abstract: In a double-blind investigation, comprising 300 gynaecological patients, the prophylactic use of droperidol i.v. at the start of the anaesthesia produced significant reduction in the frequency of nausea and vomiting postoperatively in the first 24 h from 34.4% to 10.3% (P=0.0001). There was no significant difference between the effect of droperidol 2.5 mg and 5 mg (P=0.45). Increased postoperative sedation was the only side-effect of any importance observed; however, this did not result in any increased period of observation in the recovery room, and the majority of patients considered it advantageous. Droperidol is recommended as a prophylactic anti-emetic for selected groups of patients, given as 2.5 mg i.v. at the start of the anaesthesia.

Postoperative Analgesia and Lung Function: a Comparison of Intramuscular with Epidural Morphine

Abstract: Thirty healthy patients subjected to cholecystectomy or operation for duodenal ulcer were allocated randomly for postoperative analgesic treatment with morphine i.m. or epidurally. Morphine was given only at the request of the patients and only as much was given as was needed to obtain satisfactory pain relief. Patients in the epidural group were given morphine exclusively by epidural injection. In the epidural group a lower incidence of radiological changes in the lungs was found postoperatively - 21 % as against 67%. Compared with the i.m. group, there was a higher arterial oxygen tension and a slower increase in alveolar-arterial oxygen difference. It is concluded that epidural morphine analgesia reduces the degree of postoperative lung dysfunction compared with conventional i.m. morphine treatment.

A Study of EGG Abnormalities and Myocardial Specific Enzymes in Patients with Subarachnoid Haemorrhage

Abstract: Twenty-two patients with subarachnoid haemorrhage were investigated for changes in myoglobin, total CK, CK-MB and CK-BB in serum and for the incidence of ECG abnormalities. Serial ECG's showed abnormalities in 20 patients; 15 of these had T wave changes, 15 Q-Tc prolongation, ten had S-T depression and nine U waves and in seven cases arrhythmias were found. The purpose of the study was to find out whether a relationship could be established between the ECG abnormalities and changes in serum myoglobin and enzymes. However, in no patient could myoglobin or enzyme patterns consistent with acute myocardial or cerebral damage be observed and therefore the ECG abnormalities do not seem to be related to detectable myocardial damage.

Cardiovascular Effects of Continuous Intravenous Anaesthesia Compared with those of Inhalational Anaesthesia

Abstract: Comparisons between the cardiovascular effects of inhalation and intravenous anaesthetics have only recently been possible, either in man or animals. This has been a result of the development of intravenous agents which can be administered as a continuous infusion to maintain a steady-state concentration of drug in the plasma. When intravenous anaesthetics are used to induce anaesthesia, the peak plasma concentrations following a single bolus injection reach much higher levels than those required for steady-state anaesthesia, and then the plasma concentration decays in a multiple exponential fashion as anaesthesia is maintained with different agents. Thus, while cardiovascular measurements made before and during the course of induction are useful in characterizing the various agents, such measurements do not stand comparison with those during steady-state anaesthesia.

Cannulation of the internal jugular vein - 500 cases.

Abstract: Five hundred consecutive cases of internal jugular vein catheterization are presented. The success rate varied from 88% in infants under 1 year of age to 99% in adults. There were 16 arterial punctures (3.2%). In one patient surgical removal of a haematoma was necessary. No pneumothorax occurred. Compared to other techniques for central venous catheterization, the internal jugular vein approach gives a high incidence of correct catheter positions and few complications, and is thus recommended.

Ethical and clinical aspects of pain treatment in cancer patients.

Abstract: (4) All treatment has an inherent risk. literally means death without suffering, is now generally defined as bringing about the death ofa human being on purpose as part of the medical care being given him. In relation to the terminally ill, a more precise functional definition is helpful the administration of a drug (or drugs) deliberately and specifically to precipitate or accelerate death in order to terminate suffering. Unfortunately, much that is said and written about euthanasia fails to distinguish between deliberate death acceleration and matters such as adequate pain relief and eventually all his patients will die.

Effect of Posttraumatic Epidural Analgesia on the Cortisol and Hyperglycaemic Response to Surgery

Abstract: Plasma cortisol and glucose were measured in 36 patients undergoing abdominal hysterectomy under either general anaesthesia (Group I), epidural analgesia (T4-S5) effective before surgery (Group II) or general anaesthesia plus epidural analgesia (T4-S5) effective from 30 min after initiation of surgery. The results confirmed that epidural analgesia effective before skin incision (Group II) prevented the normal per-and postoperative increase in plasma cortisol and glucose. Patients receiving posttraumatic epidural analgesia (Group III) showed the normal initial increase in plasma cortisol and glucose, but initiation of epidural analgesia immediately broke the stress-response and prevented any further increase in plasma cortisol and glucose. However, although posttraumatic neurogenic blockade inhibited a major part of the stress-response, resting endocrine-metabolic activity was not reestablished, suggesting that once released the endocrine-metabolic response to trauma leads to persistent changes even if further afferent stimuli from the traumatized area are prevented.

Pharmacological evacuation of the stomach with metoclopramide.

Abstract: Children admitted for emergency operations because of trauma run a high risk of chemical aspiration pneumonitis syndrome. Fifty-eight children admitted for closed reduction of fractures and suturing of wounds were studied in a double-blind manner in order to see if metoclopramide could be of value in decreasing the risk of aspiration during anaesthesia. Metoclopramide given before anaesthesia proved to enhance gastric evacuation and could thus be of value in these situations. In addition, the study showed that the time from last oral intake until start of anaesthesia is of less importance then the type of trauma in prolonging the gastric emptying time and thus increasing the risk of vomiting and aspiration of vomitus into the lungs during anaesthesia.