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Showing papers in "BJA: British Journal of Anaesthesia in 1982"


Journal ArticleDOI
TL;DR: Patients aged 70 yr or more, those receiving thoracic extradural puncture and those with reduced ventilatory capacity seemed to be oyerrepresented, and the administration of extradural morphine was considered as a major contributory factor for the occurrence of Ventilatory depression.
Abstract: The Swedish Society of Anaesthetists conducted a nationwide retrospective survey of clinical experience with extradural and intrathecal opiates. Special interest was focused on the frequency and type of ventilatory depression. The questionnaire was answered by 84 of 93 departments (90%). Up to May 1981 extradural morphine had been given to approximately 6000-9150 patients, extradural pethidine to 220-450 and intrathecal morphine to 90-150 patients. Ventilatory depression requiring treatment with naloxone was reported in 23 patients treated with extradural morphine (0.25-0.40%) and in six given intrathecal morphine (4-7%). In 22 patients the administration of extradural morphine was considered as a major contributory factor for the occurrence of ventilatory depression. Only two of these 22 patients experienced ventilatory depression later than 6 h after the last dose of opiates (S.C., i.m., i.v. or extradural). Patients aged 70 yr or more, those receiving thoracic extradural puncture and those with reduced ventilatory capacity seemed to be overrepresented.

315 citations


Journal ArticleDOI
TL;DR: A divergence in the specificity of the analgesic action of lignocaine i.v. according to the nature of the pain-inducing process is suggested, whereas pain of peripheral origin is unaffected by lignOCaine, except at blood concentrations which approach toxic values.
Abstract: SUMMARY The analgesic effect of I.V. lignocaine was evaluated in five paoents with clinical neuralgic pain of varying aetiology. The response was compared with that on concurrently-induced ischaemic pain, initially of the same intensity Following a high dose infusion of 3 ing kg (lignocaine concentrations greater than 3 fig ml ) both pains were decreased, clinical pain to a significantly greater extent. Thereafter, at lower doses and blood concentrations, lignocaine was without effect on ischaemic pain, but almost totally suppressed the same patient's rlimral pain. The results suggest a divergence in the specificity of the analgesic action of lignocaine I .v. according to the nature of the pain-inducing process. Disorders manifesting as deaffcrematio n or central neuralgias appear to be affected favourably by lignocaine i.v., whereas pain of peripheral origin is unaffected by lignocaine, except at blood concentrations which approach toxic values. The ability of lignocaine to suppress irritable foci in the heart and brain (Covino and Vassallo, 1976), has proved to be of value in the treatment of ventricular arrhythmias and epileptic seizures. Pain associated with neurological deafferentation may have spinal electrogram patterns characterized by highfrequency burst discharge activity in neurons of the central nervous system (Loeser, Ward and White, 1968; Anderson et al., 1971). Since this discharge activity may be similar in nature to ectopic activity in the heart or epileptic activity in the cerebral cortex it seemed worthwhile considering the use of lignocaine i.v. as an analgesic agent in patients presenting with appropriate features of neurological deafferentation disorders. Some support for this concept could be derived from earlier clinical experience in the treatment of pain of postherpetic neuralgia (Hatangdi, Boas and Richards, 1976).

205 citations


Journal ArticleDOI
TL;DR: It is concluded that alfentanil is less cumulative than fentanyl, has restricted hepatic clearance, and will exhibit non-linear kinetics at very high doses.
Abstract: The pharmacokinetics of fentanyl and alfentanil were compared by the simultaneous i.v. administration of both drugs, measurement of plasma concentrations and compartmental analysis. In addition, plasma protein binding, erythrocyte: plasma partition, and heptane: water partition were compared. Alfentanil was found to have a very much smaller apparent volume of distribution, smaller total clearance, and shorter terminal half-time in plasma. Alfentanil was also found to have a greater plasma protein binding, but in contrast to fentanyl, no binding to erythrocytes It is concluded that alfentanil is less cumulative than fentanyl, has restricted hepatic clearance, and will exhibit non-linear kinetics at very high doses. An appendix describes the model-fitting procedure in detail.

204 citations


Journal ArticleDOI
TL;DR: Clinical assessment of neuromuscular transmissionの 始 ま りであ ろう。
Abstract: 1958年,ChristeとChurchill-Davidson1)は 筋 弛 緩薬 に よ る術 後遷 延性 無 呼 吸 の診 断 に,1960年, Churchill-DavidsonとWise2)は 術 後遷延 性 無呼 吸 の予防,診 断,治 療 のためにnerve Stimulator(神 経刺激器)を 使 って神経筋伝達機能 を評価 す るこ と が い か に有 効 で あ る か を報 告,こ れ がClinical assessment of neuromuscular transmissionの 始 ま りであ ろう。 その後 もKitz3), Ali & Savarese4) が筋弛緩 のモニタ リング法 について紹介 したが,そ の成果 は筋弛緩薬 その ものの研 究面 に応用 され るの が主であった。世界各国で 日々の臨床麻酔 と直結 し た筋弛緩 のモニタ リングの必要性 が本格 的 に論議 さ れ出 した のは,1979年Viby-Mogensenら5)に よ り いわゆ る臨床的徴候のみで残存 筋弛緩 を判定 した場 合,予 想 をは るか に上 回 る強 い残 存筋 弛緩 が30% 異常の発生頻度 で存在 す る とい う報 告 を皮切 りに, 1986年 にBeemerら6),1988年 にBevanら7)に よって次々 とそれ ぞれの施設 の残存筋弛緩 の発生頻 度 の報告が あ り,こ れ らが大 きな契機 となって臨床 に直結 した筋弛緩モニタ リングが急速 に発展 して き た。 その後国 内で は1993年4月,日 本 麻酔学 会 よ り 「安全 な麻 酔 のた めのモニ ター指針」 のなか で, その使用が勧 められ るに至った。 パル スオ キシメーターに よる経皮 的血液酸素飽和

171 citations


Journal ArticleDOI
TL;DR: The permeability of cranial and lumbar dura to various substances including a number of narcotic analgesics was measured in vitro and indicated that drug molecular weight and rate of absorption are important determinants of the efficiency of dural transfer.
Abstract: SUMMARY The permeability of cranial and lumbar dura to various substances including a number of narcotic analgesics was measured in vitro. Preliminary data on human postmortem material is reported. Permeability had g linear relation to the inverse of the square root of molecular weight. This is the expected relationship for a diffusion process dependent upon molecular weight. The differential mass selectivity coefficients for lumbar and cranial dura were calculated; they were similar at 0.8 and 0.9. This was greater than for diffusion in simple liquids, but much less than that for biological lipid membranes. This suggests that the low rates of diffusion are a property of the thickness of the dura rather than any inherent impermeability. A simple model for the dural transfer of drugs is described, and applied to narcotics. Its purposes were to suggest: the factors involved in the dural transfer of drugs; the physicochemical properties of drugs relevant to their dural transfer; worthwhile measurements in future studies. The model indicates that drug molecular weight and rate of absorption are important determinants of the efficiency of dural transfer. Low molecular weight and slow absorption produce high dural transfers. When applied to narcotics, these factors could produce a difference of up to an order of magnitude in the amount transferred directly across the dura.

159 citations


Journal ArticleDOI
S. C. Farrow1, F. G. R. Fowkes1, J. N. Lunn1, I. B. Robertson1, P. Samuel1 
TL;DR: The hospital mortality following anaesthetics in Cardiff between 1972 and 1977 has been analysed and data is presented on several important variables that influence mortality.
Abstract: The hospital mortality following 108 878 anaesthetics in Cardiff between 1972 and 1977 has been analysed. There was a total of 2391 deaths, giving a crude mortality rate of 2 2 per 100 patients. Data are presented on several important variables that influence mortality These include age, sex, preoperative clinical assessment score, preoperanve condition, site of operation, operation, whether elective or emergency and duration of anaesthesia

138 citations


Journal ArticleDOI
TL;DR: Analgesia was more rapid in onset and more complete in the fentanyl group, and the duration from first dose to first top-up was 2.36 h, compared with 1 66h (supplements notwithstanding) in the control group.
Abstract: In a double-blind trial carried out on patients in the first stage of labour, either fentanyl 80 μg (n = 35) or physiological saline (n=33) was added to the test dose of bupivacaine and administered extradurally Thereafter analgesia was maintained as necessary with 0.5% bupivacaine alone Supplementary bupivacaine (a further dose within 1 h) was required to produce satisfactory analgesia in eight patients in the fentanyl group and in 26 patients in the control group. Analgesia was more rapid in onset and more complete in the fentanyl group, and the duration from first dose to first top-up was 2.36 h, compared with 1 66h (supplements notwithstanding) in the control group No serious side-effects were encountered in either group, although eight patients in the fentanyl group experienced mild itching, compared with one in the control group

137 citations


Journal ArticleDOI
TL;DR: The data suggest that the elimination half-life of fentanyl is not primarily influenced by the rate at which it is metabolized in the liver.
Abstract: Fentanyl kinetics were studied in patients with cirrhosis and in patients with normal hepatic and renal function undergoing surgery under general anaesthesia, the latter group served as the controls. Plasma fentanyl concentrations declined bi-exponentially in the controls with an average elimination half-life (T½β) of 263 mm; total plasma clearance (C7) was 10.8mlmin−1kg−1, and total apparent volume of distribution (Vβ) 3 81 litre kg−1. No significant change was observed in patients with cirrhosis: T(T½β) was 304mm, Cl 11.3 ml min−1 kg−1 and Vβ 4.41 litre kg−1. These data suggest that the elimination half-life of fentanyl is not primarily influenced by the rate at which it is metabolized in the liver.

119 citations


Journal ArticleDOI
TL;DR: Women were more likely to develop sore throat after intubation than were men and a possible relationship between differences in cuff-trachea contact area is postulated.
Abstract: One hundred and eighty-four patients were studied to elucidate the contribution of intracuff pressure and cuff type to the occurrence of sore throat and hoarseness after operation. The patients were allocated to one of the following groups: A = mask only; B = reusable Rusch tube with intermittent cuff volume adjustment; C = reusable Rusch tube without cuff volume adjustment; D = disposable Portex Blue Line tube with intermittent cuff volume adjustment; E = disposable Shiley Low Pressure tube with intermittent cuff volume adjustment. Nitrous oxide was a component of anaesthesia in all patients. Moderate or severe symptoms were recorded in 30-33% of the patients in groups C, D and E, contrasting with group B, in which these sequelae were seen in only 10% of patients (P less than 0.025). All sequelae occurred less frequently in group A than in any of the other groups (P less than 0.025). Women were more likely to develop sore throat after intubation than were men (P less than 0.01). A possible relationship between differences in cuff-trachea contact area is postulated.

114 citations


Journal ArticleDOI
F. G. R. Fowkes1, J. N. Lunn1, S. C. Farrow1, I. B. Robertson1, P. Samuel1 
TL;DR: Mortality was greater for emergency than for elective operations, and the relative mortality risk decreased, suggesting that in older age groups coexisting disease may be less important than other risk factors in determining mortality.
Abstract: The Cardiff Anaesthetic Record System has been used to examine the hospital mortality rates and relative risks for patients having anaesthesia who have certain preoperative conditions coexisting with their disease requiring surgery. Each preoperative condition was associated with a higher mortality rate than occurred in patients with no preoperative condition (for example ischaemic heart disease 7%, diabetes 5.7%, no preoperative condition 0 5%). Mortality was greater for emergency than for elective operations In contrast to an increasing mortality by age, the relative mortality risk decreased, suggesting that in older age groups coexisting disease may be less important than

111 citations


Journal ArticleDOI
TL;DR: A number of methods are available which fulfil the requirements to varying degrees in different applications, and this paper describes and classifies these methods, indicates the applications in which they are most useful and outlines some recent findings.
Abstract: Many drugs used in anaesthetic practice such as the opiates, sedatives, barbiturates and volatile anaesthetic agents cause respiratory depression. This often leads to a cautious use of such agents and on occasions this may lead to the administration of a dose of drug which is less than that desired for adequate therapeutic effect. This may often be the case with the administration of opiates for postoperative pain. Consequently, there is a great interest in measuring the respiratory effects of these commonly used drugs both in the laboratory and in the clinical environment, and this interest clearly extends into assessing the efficacy and safety of new compounds and of novel modes of administration of new and conventional agents. Of prime importance in such studies is the development of suitable methods for assessing the respiratory effects of these drug regimes. The methods must be able not only to quantify the degree of respiratory depression, but also detect alterations in the regulation of breathing which may indicate the potential for serious depression to occur. A number of methods are available which fulfil these requirements to varying degrees in different applications. This paper describes and classifies these methods, indicates the applications in which they are most useful and outlines some recent findings.

Journal ArticleDOI
TL;DR: The frequency and nature of the oculocardiac reflex and its prevention by atropine or glycopyrrolate (i.m. and 1 V) abhave been studied in 160 children undergoing surgery for the correction of squint in children given no anticholinergic premedication.
Abstract: SUMMARY The frequency and nature of the oculocardiac reflex and its prevention by atropine or glycopyrrolate (i.m. and 1 V) abhave been studied in 160 children undergoing surgery for the correction of squint. Ninety per cent of those given no anticholinergic premedication exhibited the reflex. This was decreased to about 50% in those receiving the drugs i.m. Giycopyrrolate 7.5 μgkg−1 and atropine 15 μgkg−1 i v. were effective in most instances, the latter being slightly better However, glycopyrrolate was associated with tachycardia of smaller magnitude. The reflex was observed more often following traction on the medial rectus muscle.

Journal ArticleDOI
TL;DR: The anaesthetic records of 600 patients undergoing lower limb surgery were reviewed to determine the frequency of intraoperative arterial hypertension and the overall frequency of hypertension during operation in 500 patients to whom a tourniquet was applied during surgery was 11%.
Abstract: The anaesthetic records of 600 patients undergoing lower limb surgery were reviewed to determine the frequency of intxaoperanve arterial hypertension (defined as a 30% increase in either systolic or diastolic pressure compared with the first pressure recording after incision). The overall frequency of hypertension during operation m 500 patients to whom a tourniquet was applied during surgery was 11% The probability of hypertension was increased if the patient was elderly, had cardiac enlargement shown by x-ray or e c g, or had nitous oxide and narcotic anaesthesia. Pre-existing hypertension, increased serum creatirune concentration, anaemia, or treatment with antihypertensives, diuretics, or steroids were not strongly associated with inrraoperative hypertension A control group of 100 patients undergoing hip surgery without application of a tourniquet exhibited hypertension in 1 % of cases

Journal ArticleDOI
TL;DR: Changes induced by etomidate are similar to those after barbiturates and other i.e. anaesthetics, however, a combination with analgesic drugs appeared to be necessary for surgical procedures.
Abstract: Etomidate was injected i.v. within 10 or 60s at various doses. After etonudate 0.3 mg kg−1 the plasma concentration was 1.6 μg ml at 1 min after the end of injection. For about 7min a good hypnotic effect (stages C0−D2) was observed on the e.e.g. recording. For surgical procedures, however, a combination with analgesic drugs appeared to be necessary. When the dose of etomidate was increased (0.1 –0.4 mg kg−1) a linear increase in plasma concentration and slow e.e.g activity was observed concomitantly. Anaesthesia could be prolonged with additional injections or with continuous infusion. Each additional injection produced a steep increase in concentration of short duration with marked deepening of hypnosis. The infusion induced only a moderate increase in plasma concentration, whereas the depth of sleep during the period of infusion remained nearly the same. E.e.g. changes induced by etomidate are similar to those after barbiturates and other i.v. anaesthetics

Journal ArticleDOI
TL;DR: The relationships between the structures and functions of the pulmonary epithelium and endothelium are outlined, and some new methods for measuring their permeability in a variety of experimental and clinical situations are described.
Abstract: This paper outlines the relationships between the structures and functions of the pulmonary epithelium and endothelium, and describes some new methods for measuring their permeability in a variety of experimental and clinical situations. Much of the work outlined in this paper is reviewed by Davies (1973), Staub (1974, 1978, 1981), Effros (1978), Staehelin and Hull (1978), Diana and Fleming (1979), and Chinard (1980). Diffuse injury of the alveolar epithelium and the pulmonary vascular endothelium may follow aspiration of gastric contents, inhalation of toxic smokes and vapours or pulmonary embolism. Similar damage may occur when the complement system is activated during haemodialysis and after trauma or infection (Hammerschmidt et al., 1980). Complement activation has also been reported after cardiopulmonary bypass (Chenoweth et al., 1981) but no correlation was found between activation and changes in arterial oxygen tension. If any injury does occur it may cause these layers to become unduly leaky to water and solute. If the injury creates "holes" in the epithelium large enough to leak protein then pulmonary oedema will ensue, but if the leakage is minimal and confined to small molecular weight solutes there is no clinically obvious effect. A major problem in establishing the link between a potentially damaging stimulus and this minimal pulmonary response has been the lack of an objective test to measure a deterioration in function of the vascular endothelium and, in particular, the epithelial lining of the airways and alveoli. Measurements of changes in lung mechanics or gas exchange are either non-specific or too insensitive to draw any conclusions about the functional effects of this minimal lung injury. One approach could examine the effect of lung injury on pulmonary metabolism (Said, 1979) but, so far, little is known about the

Journal ArticleDOI
TL;DR: The effects of anaesthesia with sufentanil 15 micrograms kg-1, air and oxygen on the electroencephalograph were studied in 12 patients before and after cardiopulmonary bypass and the e.e.g. responses were characterized by high voltage, slow delta waves.
Abstract: SUMMARY The effects of anaesthesia with sufentanil 15 μg kg−1, air and oxygen on the electroencephalograph were studied in 12 patients before and after cardiopulmonary bypass. The e.e.g. responses were characterized by high voltage, slow delta waves. Although the mean power in the delta band declined with time, the contribution of delta power to total power in the frequency range 0.5–40 Hz remained constant until the onset of cardiopulmonary bypass. Sharp waves of uncertain neurophysiological significance were seen. They were not associated with clinical signs of epileptic activity. The use of the e.e.g. response as a monitor of "depth of anaesthesia" during high-dose opioid anaesthesia may become possible.

Journal ArticleDOI
TL;DR: There were no effects of clinical importance on heart rate, respiratory frequency or arterial pressure, but arterial systolic pressure decreased after morphine and pethidine, and Pethidine caused a statistically significant reduction in diastolic pressure.
Abstract: The effectiveness of extradural injections of morphine sulphate 6 mg, methadone 6 mg, pethidine 60 mg and fentanyl 60 μg in reheving pain after operation were compared in 24 patients. The average duration of pain relief following morphine was 12.3 h; methadone 8 7 h, pethidine 6 6 h and fentanyl 5 7 h. There was no significant difference m the efficacy of the four drugs. There were no effects of clinical importance on heart rate, respiratory frequency or arterial pressure, but arterial systolic pressure decreased after morphine and pethidine. Pethidine also caused a statistically significant reduction in diastohc pressure.


Journal ArticleDOI
TL;DR: The effects of age on the dose of Org NC45 were studied in 24 healthy, anaesthetized patients using an on-demand infusion of the drug which produced a stable twitch height of 10% of its initial value.
Abstract: The effects of age on the dose of Org NC 45 were studied in 24 healthy, anaesthetized patients using an on-demand infusion of the drug which produced a stable twitch height of 10% of its initial value. The patients were allocated as follows: group I = age less than 40 yr; group II = 40-60 yr and group III = age greater than 60 yr. A steady-state dose measured every 10 min, was achieved in all the patients 30 min after the start of the administration of Org NC 45. Significant decreases of steady-state dosage requirement (P = 0.01) and rate of recovery from blockade (P less than 0.01) were observed between group III and the other two groups.

Journal ArticleDOI
TL;DR: C cortisol and glucose concentrations were greater after operation in patients receiving extradural morphine compared with extradural bupivacaine, suggesting that the endocrine metabolic response to surgery is predominantly released by neurogenic stimuli other than pain stimuli involving opiate receptor-dependent nociceptive pathways.
Abstract: SUMMARY Plasma cortisol and glucose concentrations were measured repeatedly from before the induction of anaesthesia until 9 h after skin incision in 36 patients undergoing abdominal hysterectomy. Twelve patients received general anaesthesia (halothane), and systemic opiates for postoperative pain; a further 12 patients underwent continuous extradural analgesia with a local anaesthetic agent (bupivacaine) and in the remaining 12 patients general anaesthesia (halothane) plus extradural morphine (4 mg before skin incision and an additional 4 mg at skin closure) were used. Patients receiving extradural morphine or bupivacaine were free of pain. The physiological cortisol and glucose response to surgery was blocked by the extradural analgesia with bupivacaine. Extradural morphine did not modify the initial increase in plasma cortisol and glucose concentrations during surgery, but suppressed the hypcrglycaemic and cortisol response following surgery when compared with the general anaesthesia group receiving systemic opiates. However, cortisol and glucose concentrations were greater after operation in patients receiving extradural morphine compared with extradural bupivacaine, suggesting that the endocrine metabolic response to surgery is predominantly released by neurogenic stimuli other than pain stimuli involving opiate receptor-dependent nociceptive pathways

Journal ArticleDOI
TL;DR: The studies confirmed the known antanalgesic action of thiopentone and demonstrated that diisopropyl phenol has an analgesic action which is an attractive feature in an i.v. anaesthetic agent.
Abstract: The response to somatic pain with sub-hypnotic doses of ICI 35 868 (dusopropyl phenol in cremophor) and thiopentone was compared using tibial pressure algesimetry. Studies were also earned out following recovery from larger doses of both drugs. The patients underwent minor gynaecological procedures using only one of the two i.v. agents and nitrous oxide in oxygen. The studies confirmed the known antanalgesic action of thiopentone and demonstrated that dusopropyl phenol has an analgesic action which is an attractive feature in an i v anaesthetic agent.

Journal ArticleDOI
TL;DR: The three drugs provided equal and generally good intubating conditions at approximately 95% twitch depression, and greater arterial pressure and heart rate were seen with pancuronium than with atracurium and Org NC 45.
Abstract: The potencies of atracurium, Org NC 45 and pancuronium were determined using cumulative dose-response curves. The effective doses producing 95% twitch depression were 279 μgkg -1 , 56 μg kg -1 and 64μg kg -1 respectively, the relative potency being 1:5.0:4.3. The calculated log-probit dose-response curves showed the steepest slope for pancuronium, although the slopes did not deviate significantly from the parallel. The three drugs provided equal and generally good intubating conditions at approximately 95% twitch depression. Greater arterial pressure and heart rate were seen with pancuronium than with atracurium and Org NC45.

Journal ArticleDOI
TL;DR: It is concluded that the type of reaction to neostigmine in patients with neuromuscular disease is unpredictable and attempts to reverse residual non-depolanzmg block with neostIGmine 1.0 mg were only partially effective.
Abstract: In a 57-yr-old female with dystrophia myotonica, attempts to reverse residual non-depolanzmg block with neostigmine 1.0 mg were only partially effective and the administration of a further dose (0.5 mg) produced long-lasting muscle weakness. The train-of-four response of this patient resembled that of a depolarizing block and suggested an alteration in the electrical properties of the muscle membrane A 50-yr-old male with a 30-yr history of progressive muscle dystrophy, exhibited a tonic response to neosugmine in the evoked mechanomyogra M. During recovery from partial neuromuscular block. It is concluded that the type of reaction to neostigmine in patients with neuromuscular disease is unpredictable.

Journal ArticleDOI
R. Ellis1, D. Haines1, R. Shah1, B.R. Cotton1, George Davey Smith1 
TL;DR: There were no significant differences between analgesic regimens in respect of subjective linear analogue pain scores or static and dynamic lung volumes assessed at 24 and 48 h after operation and 5 days after operation in patients who underwent upper abdominal surgery.
Abstract: One hundred and twenty-six patients undergoing upper and lower abdominal surgery were studied after operation to compare the analgesic effects of 1.m morphine, sublingual buprenorphine and self-administered 1 v. pethidine by Cardiff Palliator There were no significant differences between analgesic regimens in respect of subjective linear analogue pain scores or static and dynamic lung volumes assessed at 24 and 48 h after operation and 5 days after operation in patients who underwent upper abdominal surgery. Sublingual buprenorphine produced more nausea and sedation than the other two treatments, but the differences were not clinically important However, it offered considerable advantages in terms of ease of administration.

Journal ArticleDOI
TL;DR: In a controlled clinical study of 20 patients undergoing arthrotomy a single dose of morphine 0.05 mg kg-1 administered extradurally resulted in more pronounced and prolonged pain relief than morphine 0% i.m. in the period immediately after operation.
Abstract: SUMMARY In a controlled clinical study of 20 patients undergoing arthrotomy a single dose of morphine 0.05 mg kg-1 administered extradurally resulted in more pronounced and prolonged pain relief than morphine 0.1 mg kg-1 i.m. in the period immediately after operation. This difference was significant between 2 and 11 h after morphine administration. The maximum analgesic effect for nine patients in the extradural group was obtained about 2 h after injection. Two of 10 in the extradural group experienced urinary retention. Other side-effects were mild for both groups. Plasma concentrations of morphine were measured in five patients in each group. Four hours after administration, morphine was not detectable in plasma in any of the extradural group and in two of the i.m. group. Our study gives further support for the theory that extradural morphine acts on the spinal cord.

Journal ArticleDOI
TL;DR: The uses of high concentrations of therapeutic oxygen have expanded in recent decades both from the introduction of ventilation by intubation in the Intensive Care setting and with the use of hyperbaric oxygen for the treatment of anaerobic infections.
Abstract: The uses of high concentrations of therapeutic oxygen have expanded in recent decades. This situation came about both from the introduction of ventilation by intubation in the Intensive Care setting and with the use of hyperbaric oxygen for the treatment of anaerobic infections. Furthermore, high concentrations of oxygen have been used in deep sea diving and in aviation and space exploration. With potential side-effects of exposure to high concentrations of oxygen it has become increasingly important to understand better the parameters of exposure that produce toxicity, the mechanisms by which it occurs and the potential protective devices against its tissue-damaging effects. It is the purpose of this review to address these considerations. The reader is also referred to other reviews (Clark and Lambertsen, 1971; Mustafa and Tierney, 1978; Deneke and Fanburg, 1980a; Fisher, 1980; Frank and Massaro, 1980) where certain aspects of the subject may be covered in more detail. Damage to tissues by oxygen seems to be related more to the partial pressure of oxygen than to its percent concentration. Hence, a high concentration of oxygen may be less damaging at high altitude where the atmospheric pressure is reduced than it is for the same concentration at normobaric pressure. The primary target of injury for normobaric hyperoxia is the lung, probably at least in part because lung cells are exposed to higher partial pressures of oxygen than are other cells of the body. With hyperbaric hyperoxia, the rapid onset of convulsions indicates that the central nervous system shows the earliest signs of toxicity. Hence, with higher partial pressures of oxygen than can be achieved under normobaric conditions, tissues of the central nervous system seem to be \"more sensitive\" than do cells of the lung. It is likely that certain

Journal ArticleDOI
TL;DR: It is suggested that the injection of Valium should be avoided except in large antecubital veins, although even here the complication rate is higher than with Diazemuls.
Abstract: The frequency of pain on injection and the occurrence of venous sequelae were assessed following the i.v. administration of certain anaesthetic and sedative drugs. Pain on injection occurred frequently following injection in the small veins of the forearm or hand. Pain on injection was greatest with diazepam in organic solvent (Valium) (37%), infrequent with midazolam (1%) and not elicited with diazepam in soya bean oil (Diazemuls). About one in 10 patients complained of pain following thiopentone or methohexitone There was a 40% frequency of venous thrombosis, assessed on the 7-10th days after Valium This was virtually absent with Diazemuls and midazolam. A 10% frequency was found following 1% methohexitone and disoprofol (ICI35 868). We suggest that the injection of Valium should be avoided except in large antecubital veins, although even here the complication rate is higher than with Diazemuls.

Journal ArticleDOI
TL;DR: Extradural and i.m groups showed the same pharmacokinetic patterns although extradural analgesia is much more prolonged, and Morphine glucuronide appeared later in blood in the intrathecal group than in the two other groups.
Abstract: Eighteen patients received morphine 02 mgkg −1 in 9% saline im (n = 6), extradurally(n = 6), or in a 10% dextrose solution intrathecally (n = 6) for pain relief after operation Plasma unmetabolized morphine was isolated by extraction using liquid-solid chromatography and measured by radioimmunoassay Conjugated morphine was calculated from the difference between total immunoreactive morphine and unmetabolized morphine Initial vascular absorption was significantly less in the intrathecal group than in the im and extradural groups This accounts for persistence of plasma unmetabolized morphine at 24 h and for more prolonged analgesia in the intrathecal group Prolonged analgesia observed following extradural and intrathecal administration was caused by a small quantity of unmetabolized morphine Extradural and im groups showed the same pharmacokinetic patterns although extradural analgesia is much more prolonged Morphine glucuronide appeared later in blood in the intrathecal group than in the two other groups

Journal ArticleDOI
TL;DR: A comparison with previous work suggests that increased efficacy results either from the use of the larger dose or equivalently if the first required postoperative dose of 0.3 mg has been preceded by a similar loading dose.
Abstract: SUMMARY The plasma concentrations and clinical effects of a single i.v. dose of buprenorphine 0.3 or 0.6 mg were studied in patients recovering from surgery. Analgesic and hormonal effects were greater with the greater dose without a parallel increase in respiratory depression. A comparison with previous work suggests that increased efficacy results either from the use of the larger dose or equivalently if the first required postoperative dose of 0.3 mg has been preceded by a similar loading dose.

Journal ArticleDOI
TL;DR: Circulating insulin values were significantly decreased in the extradural group of patients, confirming the importance of autonomic innervation in maintaining basal insulin output.
Abstract: The effect of thoracic extradural analgesia and vagal blockade on the metabolic t-1 endocrine responses to cholecystectomy was investigated. In comparison with a control grjf patients, extradural analgesia and vagal blockade abolished the glycaemic response to surgr jut had no effect on the increase in plasma cortisol. Circulating insulin values were significantly decreased m the extradural group of patients, confirming the importance of autonomic innervatir in maintaining basal insulin output. There is, at present, no satisfactory local analgesic technique for controlling the endocrine response to upper abdominal surgery.