Anaesthesia
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This audit study took place in ten outpatient pain clinics and focused on the management of low back pain and nerve-damage pain. The objective was to identify and promote appropriate changes in management. An analysis of the treatment of 1236 patients with low back pain and/or nerve-damage pain highlighted wide variations in practice. ⋯ Many changes in practice occurred after the audit intervention, with large increases in the utilisation of these three treatments. Since there is reasonable evidence to support the use of these treatments for chronic pain this represents an improvement in the process of care. The audit demonstrated that patient management can be improved by a combination of active feedback and discussions based around comparisons between centres.
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Bleeding caused by inhibitors to factor VIII is a rare medical emergency requiring immediate specialist investigation and management. Urgent initiation of therapy with high dose factor VIII concentrates may be life saving. Successful management of acute upper airway obstruction from uncontrolled haemorrhage into the oropharyngeal tissues should be achieved with fibreoptic guided nasotracheal intubation.
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Randomized Controlled Trial Comparative Study Clinical Trial
A comparison of epidural infusions of fentanyl or pethidine with bupivacaine in the management of postoperative pain.
A double-blind randomised clinical trial was undertaken in 40 patients undergoing major abdominal surgery. Postoperative pain relief was provided using epidural infusions of 0.06% bupivacaine with fentanyl 4 micrograms.ml-1 (n = 20) (group F) or with pethidine 1.5 mg.ml-1 (n = 20) (group P). Postoperative pain scores using a visual analogue scale (0-100 mm) were not significantly different between the two groups. ⋯ Nine patients were withdrawn from the study (four from group F, five from group P) due to failure of the epidural technique or other complications. Fourteen patients, equally distributed, required a total of 24 epidural 'top-ups' by an anaesthetist because of inadequate analgesia. We demonstrated no advantage with epidural pethidine over fentanyl when used by infusion in combination with bupivacaine in the management of postoperative pain.
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Case Reports
The use of a non-invasive method to measure intrapulmonary shunt during one-lung anaesthesia.
The Non Invasive Virtual Shunt computer program has previously been described and validated. The system has subsequently been developed to give a real time, continuous trace of virtual shunt. ⋯ The equipment was used to monitor shunt before, during and after surgery in three patients. In one case, a displaced double lumen bronchial tube was detected before there was any other indication of the problem.
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Randomized Controlled Trial Comparative Study Clinical Trial
Topical lignocaine and thiopentone for the insertion of a laryngeal mask airway; a comparison with propofol.
We assessed conditions for insertion of a laryngeal mask airway in 90 unpremedicated adult patients who received either thiopentone 5 mg.kg-1 preceded by 40 mg of topical lignocaine spray to the posterior pharyngeal wall or propofol 2.5 mg.kg-1 alone in a randomised, single-blinded trial. All patients received fentanyl 1 microgram.kg-1. ⋯ The decrease in systolic and diastolic blood pressure, following induction and the insertion of a laryngeal mask with propofol was significantly greater than following thiopentone (p < 0.05--systolic, p < 0.01--diastolic). We conclude that thiopentone preceded by topical lignocaine spray provides conditions for insertion of a laryngeal mask equal to those of propofol, with more haemodynamic stability and a shorter period of apnoea.