Showing papers in "Anaesthesia in 1983"
TL;DR: Frequency analysis suggests that, in obstetrics, the main cause of trouble is grade 3, in which the epiglottis can be seen, but not the cords, which is fairly rare, and can be helpful as part of the training before starting in the maternity department.
Abstract: Difficult intubation has been classified into four grades, according to the view obtainable at laryngoscopy. Frequency analysis suggests that, in obstetrics, the main cause of trouble is grade 3, in which the epiglottis can be seen, but not the cords. This group is fairly rare so that a proportion of anaesthetists will not meet the problem in their first few years and may thus be unprepared for it in obstetrics. However the problem can be simulated in routine anaesthesia, so that a drill for managing it can be practised. Laryngoscopy is carried out as usual, then the blade is lowered so that the epiglottis descends and hides the cords. Intubation has to be done blind, using the Macintosh method. This can be helpful as part of the training before starting in the maternity department, supplementing the Aberdeen drill.
2,265 citations
TL;DR: A retrospective review of 428 severely injured patients admitted to an intensive therapy unit between 1969 and 1982 found an increased mortality was confined to ventilated patients surviving more than 5 days from injury and was associated with multiple organ failure and severe infection.
Abstract: A retrospective review of 428 severely injured patients admitted to an intensive therapy unit between 1969 and 1982 was performed. The patients' primary injuries were assessed using the injury severity score (ISS), and subsequent complications using the complications impact index and sepsis score. Between 1969 and 1980 mortality fluctuated between 19% and 29% but rose to 47% (p less than 0.05) during 1981-82 in spite of an unchanged ISS. The increased mortality was confined to ventilated patients surviving more than 5 days from injury and was associated with multiple organ failure and severe infection. The rapid and sustained increase in mortality could not be explained by any obvious change in severity of injury or referral pattern. The only deliberate change in management related to the combination of analgesic/sedative drugs used in ventilated patients. During 1979 to 1982 mortality was 28% in patients given morphine with or without benzodiazepines and 77% in those given morphine and etomidate (p less than 0.0005). After discontinuation of the latter regimen (May 1983) and resumption of the former analgesic/sedative combination, mortality fell to 25% (p less than 0.005). Possible mechanisms leading to increased mortality include adrenocortical insufficiency or depth of anaesthesia.
210 citations
TL;DR: Di‐isopropylphenol (ICI 35,868; propofol) has been reformulated as an emulsion and the overall quality of induction was assessed as good or adequate in 92% of patients.
Abstract: In order to avoid Cremophor-related reactions and reduce the incidence of pain on injection, diisopropylphenol (ICI 35,868; propofol) has been reformulated as an emulsion. One hundred and fifteen patients received an induction dose of propofol in the new formulation. The dose required to induce anaesthesia in 95% of healthy, unpremedicated patients was 2.5 mg/kg. Induction was associated with a degree of cardiovascular and respiratory depression. There were no adverse reactions although there were a number of minor side-effects. The incidence of pain on injection was low (3%) and the overall quality of induction was assessed as good or adequate in 92% of patients.
181 citations
TL;DR: It is concluded that, provided adequate precautions are taken, epidural analgesia can be safely used in patients receiving anticoagulant therapy.
Abstract: One thousand lumbar epidural blocks in 950 patients undergoing vascular surgery are reported. All patients were receiving oral anticoagulants pre-operatively. Mean thrombotest (TT) was 19.3% (normal range 70-130%). During surgery intravascular heparin was administered. At the end of surgery, the kaolin cephalin clotting time (KCCT) was 68 (+/- 0.8) seconds (normal range 35-60 seconds), and partial thromboplastin time (PTT) was 536 (77.9%, normal control of 100%). Despite the anticoagulant therapy, no side effects were observed in any patient which could be related to haemorrhage or haematoma formation in the epidural space. It is concluded that, provided adequate precautions are taken, epidural analgesia can be safely used in patients receiving anticoagulant therapy.
176 citations
TL;DR: The absence of hypotension or respiratory depression is of obvious benefit in anaesthesia for trauma, but central effects and short duration of surgical analgesia would appear to limit this application of ketamine.
Abstract: Intrathecal ketamine, which has not previously been described in man, has been administered to 16 patients with war injuries of the lower limbs. The first five received varying doses from 5 to 50 mg in a volume of 3 ml of 5% dextrose, to determine a dose-response curve (Group 1). The optimal dose was then administered to a further 11 patients who received ketamine 50 mg in a volume of 3 ml in 5% dextrose with the addition of adrenaline 0.1 mg (Group 2). A distinct sensory level was obtained in all patients. In Group 2, nine of the eleven patients obtained satisfactory surgical analgesia and two required supplementation with local anaesthetic. Central effects (drowsiness, dizziness, and nystagmus) also occurred in nine patients, but they remained conscious throughout; one patient experienced no central effects, and one patient developed dissociative anaesthesia. Central effects were more intense the higher level of block. There were no significant changes in mean systolic arterial blood pressure, pulse, or respiratory rates. Surgical analgesia for the blocked dermatomes lasted for a mean of 58 minutes (range 45-90), and recovery was complete and uncomplicated; mild generalised analgesia persisted for a further one to three hours following return of sensation. Ketamine alone did not produce motor block, but addition of adrenaline resulted in complete motor block, and may have intensified sensory blockade. Motor loss persisted for the same duration as surgical analgesia. Adrenaline neither delayed the onset of central effects, nor reduced their intensity.(ABSTRACT TRUNCATED AT 250 WORDS)
141 citations
TL;DR: A study of cricoid pressure was undertaken to relate the applied cricoids force with the resulting intraluminal cricopharyngeal (or oesophageal) pressure and it was judged to be effective in protecting the majority of adult patients from regurgitation.
Abstract: A study of cricoid pressure was undertaken to relate the applied cricoid force with the resulting intraluminal cricopharyngeal (or oesophageal) pressure. The results indicate that whilst there was a wide range in normal adults a cricoid force of 44 N was judged to be effective in protecting the majority of adult patients from regurgitation.
130 citations
TL;DR: A regression analysis revealed no difference in analgesic effect between cream and placebo when application times were less than 60 minutes, and a cusum test showed that the effect of the cream became evident at about 60 minutes.
Abstract: Summary
This study was designed to assess the effect of time on the analgesic effect of a local anaesthetic cream consisting of a mixture of 5% lignocaine and prilocaine. The cream and placebo were compared in a double-blind, randomized study in 114 children aged 4–17 years, with application times of 20 minutes and longer. A regression analysis revealed no difference in analgesic effect between cream and placebo when application times were less than 60 minutes. A cusum test showed that the effect of the cream became evident at about 60 minutes. Local adverse reactions consisted mainly of transient paleness of the skin, which did not constitute any clinical problem.
119 citations
TL;DR: This is a review of glycopyrrolate whose function in clinical practice is compared with that of atropine.
Abstract: This is a review of glycopyrrolate whose function in clinical practice is compared with that of atropine.
119 citations
TL;DR: Wc read with interest the case report on cardiac arrest in quoted as finding that 'dye injected into a peripheral vcin near term pregnancy by Lindsay and Hanson (Anorsthesin during cardiopulmonary resuscitation takes over 30).
Abstract: Wc read with interest the case report on cardiac arrest in quoted as finding that 'dye injected into a peripheral vcin near term pregnancy by Lindsay and Hanson (Anorsthesin during cardiopulmonary resuscitation takes over 30
111 citations
TL;DR: The proposed concept of CATIA provided an adequate analgesic and hypnotic effect during anaesthesia for abdominal surgery with a recovery period of short duration.
Abstract: In six patients undergoing gynaecological surgery computer assisted total intravenous anaesthesia (CATIA) was performed using etomidate and alfentanil. Constant plasma levels of etomidate (0.3 microgram/ml) from the very beginning onwards were achieved using the so called B.E.T. infusion scheme. Alfentanil plasma concentrations of 0.45 microgram/ml were maintained by the same infusion scheme beginning with skin incision until 20 minutes prior to the end of surgery. The proposed concept of CATIA provided an adequate analgesic and hypnotic effect during anaesthesia for abdominal surgery with a recovery period of short duration.
103 citations
TL;DR: A prospective study was completed of shocked patients admitted consecutively to an intensive therapy unit; the majority of patients had shock of septic origin and lactate measurements were much less valuable than serial measurements of the simple haemodynamic variables.
Abstract: A prospective study was completed of 30 shocked patients admitted consecutively to an intensive therapy unit; the majority of the patients had shock of septic origin Measurements were made of whole blood lactate together with mean arterial pressure, hourly urine volume and core: peripheral temperature difference at the start of treatment and 3 and 24 hours later Serial lactate measurements were better at predicting outcome than single measurements However, lactate measurements were much less valuable than serial measurements of the simple haemodynamic variables
TL;DR: The effects of alfentanil and fentanyl on controlling the haemodynamic responses to laryngoscopy and intubation have been compared.
Abstract: The effects of alfentanil and fentanyl on controlling the haemodynamic responses to laryngoscopy and intubation have been compared. Five groups of ten patients were studied. Induction was with thiopentone 4 mg/kg. Thirty seconds later group 1 received 1 ml/20 kg saline, group 2 received 15 micrograms/kg alfentanil, group 3 received 30 micrograms/kg alfentanil and group 4 received 5 micrograms/kg fentanyl one minute before induction. Suxamethonium was given 60 seconds after induction and intubation of the trachea was performed 150 seconds after the start of induction. Heart rate and mean arterial pressure were recorded every minute throughout and compared with pre-induction control values. Control patients (group 1) showed significant increases associated with tracheal intubation in all haemodynamic variables. No increases were noted in groups receiving 30 micrograms/kg alfentanil or 5 micrograms/kg fentanyl. The heart rate, but not blood pressure, increased with intubation after 15 micrograms/kg alfentanil. The mean time to movement in 50% of the control patients was 7 minutes. In those given 15 and 30 micrograms/kg alfentanil it was 11 and 12 minutes respectively. In those given 5 micrograms/kg fentanyl it was greater than 15 minutes. Alfentanil is shown to reduce the cardiovascular responses to laryngoscopy and intubation and the effect appears to have a shorter duration than that of fentanyl.
TL;DR: A simple test rig was developed to assess the force applied during the application of cricoid pressure yielding results which indicate an unacceptably wide variation in performance in each group.
Abstract: Summary
A simple test rig was developed to assess the force applied during the application of cricoid pressure. Anaesthetists and paramedical personnel familiar with Sellick's manoeuvre were tested yielding results which indicate an unacceptably wide variation in performance in each group. The mean force was 46.4 N but 47% failed to reach a force of 44 N.
In addition a survey was undertaken of trained anaesthetic staff to identify the current status of the manoeuvre. Of those sampled 78% routinely employed Sellick s manoeuvre and over 70% had experienced a problem with its application which exposed the patient to the risk of regurgitation.
TL;DR: Patients who had thoracic epidural analgesia required less volatile anaesthesia than the group who had general anaesthesia and narcotic analgesics; postoperative respiratory complications were more common in patients with pre‐existing cardiovascular and respiratory disease, and occurred less frequently in patients who had lymphedema.
Abstract: Summary
Seventy morbidly obese patients presented for upper abdominal surgery; 17% had pre-existing cardiovascular disease and 23% pre-existing respiratory disease. Twenty-eight patients received general anaesthesia, plus narcotic analgesia postoperatively, and 42 general anaesthesia plus thoracic epidural analgesia intra- and postoperatively. Aspects of anaesthetic management are discussed and compared with previous similar reports. Doses of local anaesthetic for induction of epidural analgesia were less than those for the non-obese but doses of local anaesthetic for maintenance of epidural analgesia were similar to those in non-obese patients. Patients who had thoracic epidural analgesia required less volatile anaesthesia than the group who had general anaesthesia and narcotic analgesics. Postoperative respiratory complications were more common in patients with pre-existing cardiovascular and respiratory disease, and occurred less frequently in patients who had thoracic epidural analgesia.
TL;DR: This is the report of the second of two studies conducted by the Association of Anaesthetists of Great Britain and Ireland based on anonymous reports of deaths within 6 days of anaesthesia, which confirms earlier results reported by the same system.
Abstract: This is the report of the second of two studies conducted by the Association of Anaesthetists of Great Britain and Ireland based on anonymous reports of deaths within 6 days of anaesthesia. One hundred and ninety-seven detailed reports were received during 1981; 43% were found by assessors to have nothing to do with anaesthesia, 41% to be partly due to, and 16% totally due to anaesthesia. These figures confirm earlier results reported by the same system. It is important to have the opinion of the two clinicians (anaesthetist and surgeon) separately and not to ignore either in a study which attempts to identify aspects of clinical medicine which might be improved.
TL;DR: A review of the case notes of 475 patients with no history of renal disorder admitted to an intensive care unit, showed that 23% developed acute renal failure, more commonly in patients with major burns and following surgery to the abdominal aorta.
Abstract: Summary
A review of the case notes of 475 patients with no history of renal disorder admitted to an intensive care unit, showed that 23% (109) developed acute renal failure. This complication occurred more commonly in patients with major burns (75%), and following surgery to the abdominal aorta (38%), but less commonly after self-poisoning episodes (5%).
Scores were provided from stepwise multiple regression analysis which were derived from the diagnostic group, the presence of sepsis, the presence of systolic hypotension and age, and correctly predicted development of acute renal failure in 79% of the cases studied. Attempted prophylaxis appears to have little effect on the incidence of acute renal failure whilst dialysis reduced the mortality from 95% to 72%. Use of the scoring system to allow earlier diagnosis and treatment of acute renal failure could reduce the present mortality by 43%.
TL;DR: It is concluded that a continuous subcutaneous infusion of morphine is a simple and effective means of achieving postoperative analgesia.
Abstract: A study was undertaken to compare continuous subcutaneous infusions of morphine with continuous intravenous infusions in patients whose lungs were mechanically ventilated for 24 hours postoperatively. Serum morphine levels were measured after the end of surgery and at 6, 12, 18 and 24 hours in nine patients receiving continuous subcutaneous morphine and in four patients receiving continuous intravenous morphine given at the same rate. At 6, 12, 18 and 24 hours the means of serum morphine levels in the intravenous group were 20 ng/ml, 17.75 ng/ml, 18.5 ng/ml and 18 ng/ml, respectively, the corresponding figures in the subcutaneous group being 23.2 ng/ml, 20 ng/ml, 20.7 ng/ml and 20 ng/ml. For the intravenous route the mean dose of supplementary analgesia was 14 mg of phenoperidine in the first 24 postoperative hours, whereas for the subcutaneous route the mean dose was 11.66 mg. The differences in the serum morphine levels and in the requirements of phenoperidine were not statistically significant. We conclude that a continuous subcutaneous infusion of morphine is a simple and effective means of achieving postoperative analgesia.
TL;DR: The degree and duration of postoperative analgesia was similar in the two groups, however, the caudal block group had a higher incidence of motor blockade and one technical failure occurred in the penile block group.
Abstract: Summary
A prospective blind trial was conducted comparing the analgesia and adverse effects produced by caudal extradural blockade (caudal block) with blockade of the dorsal nerves of the penis (penile block) in 38 boys undergoing elective circumcision. Analgesia was assessed by senior nurses using a linear analogue scale and by the response to direct questioning over the first 7 hours after surgery. The degree and duration of postoperative analgesia was similar in the two groups. However, the caudal block group had a higher incidence of motor blockade (p = < 0.01). One technical failure occurred in the penile block group.
It is concluded that a penile block is a satisfactory alternative to caudal blockade with regard to postoperative analgesia and offers several specific advantages.
TL;DR: The various intravenous agents are discussed, particularly with regard to their suitability for this form of anaesthesia, and their physiological effects compared with those of the inhalational anaesthetics.
Abstract: Total intravenous anaesthesia is a feasible alternative to the use of inhalational agents and the rationale behind such a technique is presented. The various intravenous agents are discussed, particularly with regard to their suitability for this form of anaesthesia, and their physiological effects compared with those of the inhalational anaesthetics. Some of the problems associated with the use of total intravenous anaesthesia are mentioned.
TL;DR: A case in which a mediastinal tumour caused complications including airway obstruction unrelieved by intubation during inhalational induction is described.
Abstract: A case in which a mediastinal tumour caused complications including airway obstruction unrelieved by intubation during inhalational induction is described Other case reports are reviewed and the anaesthetic management of patients with mediastinal tumours is discussed
TL;DR: It is concluded that the procedure is safe, and although the postoperative morbidity appears high it is very acceptable to the patient.
Abstract: Summary
Fifty-six women having out-patient gynaecological laparoscopies were studied to determine anasthetic problems and postoperative morbidity. It is concluded that the procedure is safe, and although the postoperative morbidity appears high it is very acceptable to the patient.
TL;DR: Pre‐oxygenation was studied in fit volunteers and patients using an oxygen flow of 8 litres/minute delivered from a standard anaesthetic machine via a Magill or Bain breathing attachment and gas‐tight fits of face masks on patients were found to be essential.
Abstract: Pre-oxygenation was studied in 12 fit volunteers and 20 patients using an oxygen flow of 8 litres/minute delivered from a standard anaesthetic machine via a Magill or Bain breathing attachment. End-tidal nitrogen concentrations of 4% or less were achieved within 3 minutes; the fastest times were achieved using the Magill breathing system when the reservoir bag was filled with oxygen prior to application to the face. Gas-tight fits of face masks on patients were found to be essential.
TL;DR: It was shown that the quality and duration of analgesia with epidural fentanyl was concentration‐dependent below 10 fig/ml, but that the addition of adrenaline abolished this phenomenon and the rate of failure to achieve any analgesia was very high with the more dilute solutions, but adrenaline reversed this problem.
Abstract: A randomised, double-blind study comparing a variety of different concentrations of fentanyl with and without 1:200 000 adrenaline is described It was shown that the quality and duration of analgesia with epidural fentanyl was concentration-dependent below 10 micrograms/ml, but that the addition of adrenaline abolished this phenomenon The rate of failure to achieve any analgesia was very high with the more dilute solutions, but adrenaline reversed this problem In general the incidences of side effects were related to the concentrations of fentanyl used and apart from itching, the incidences of these side effects were reduced by the addition of adrenaline
TL;DR: The pain relief produced by the infusion was found to be significantly better than that produced by intramuscular injections of morphine given as required in 20 children after major surgery.
Abstract: Summary
A technique is described for using morphine by continuous infusion to relieve postoperative pain in children between the ages of 1 year and 15 years. The pain relief produced by the infusion was found to be significantly better than that produced by intramuscular injections of morphine given as required in 20 children after major surgery.
TL;DR: A scheme for teaching nasotracheal intubation with the aid of fibreoptic instruments on models and live patients is described and evaluated and trainees completed 74 out of 75 intubations successfully on sedated patients to the satisfaction of themselves, their patients and their instructors.
Abstract: A scheme for teaching nasotracheal intubation with the aid of fibreoptic instruments on models and live patients is described and evaluated. Twelve trainees completed 74 out of 75 intubations successfully on sedated patients to the satisfaction of themselves, their patients and their instructors.
TL;DR: The use of linear compartment models, and of the superposition principle within these models, is discussed, and the need to achieve a concentration within the therapeutic range at the receptor site is discussed.
Abstract: Some theoretical considerations of pharmacokinetics as applied to total intravenous anaesthesia are discussed. The problem is the need to achieve a concentration within the therapeutic range at the receptor site. The use of linear compartment models, and of the superposition principle within these models, is discussed.
TL;DR: It was demonstrated that mean pain scores in the two groups were almost identical whilst sedation scores were not significantly different, and nausea scores were significantly lower in the regular morphine group.
Abstract: Summary
A double-blind study comparing a totally patient-controlled on-demand intravenous regime delivering fentanyl and a simple, regular, 4-hourly intramuscular regime delivering morphine is described It was demonstrated that mean pain scores in the two groups were almost identical whilst sedation scores were not significantly different Nausea scores were significantly lower in the regular morphine group Postoperative respiratory function tests were not significantly different in the two groups
TL;DR: The cerebral function analysing monitor is a development of the cerebral function monitor that produces a more detailed analysis of the electroencephalogram (EEG) amplitude and analyses the frequency of the waveforms into standard beta, alpha, theta and delta bands.
Abstract: The cerebral function analysing monitor is a development of the cerebral function monitor. It produces a more detailed analysis of the electroencephalogram (EEG) amplitude and analyses the frequency of the waveforms into standard beta, alpha, theta and delta bands. It can analyse the EEG from two input channels, produce traces of the standard EEG, and compute visual, auditory, somato sensory and brain stem evoked potentials.
TL;DR: Two cases of malignant hyperthermia are described where the earliest sign was a rise in the end‐tidal CO, concentration, which led to nearly immediate detection and adequate treatment with sodium dantrolene, demonstrating the efficacy of monitoring end‐expired CO2 concentrations in patients at risk from malignantHyperthermia.
Abstract: Two cases of malignant hyperthermia are described where the earliest sign was a rise in the end-tidal CO2 concentration. This led to nearly immediate detection and adequate treatment with sodium dantrolene. These cases demonstrate the efficacy of monitoring end-expired CO2 concentrations in patients at risk from malignant hyperthermia, as well as a means for following the adequacy of treatment.
TL;DR: From the results, it found it impossible to predict which patients would develop a Horner's syndrome.
Abstract: Summary
One hundred and fifty women in labour provided with extradural analgesia were monitored and an incidence of Homers syndrome of 1.33% was noted. Fifty women undergoing Caesarean section under extradural analgesia were also monitored and an incidence of Homer's syndrome of 4% was noted. From the results we found it impossible to predict which patients would develop a Horner's syndrome.